Citation Nr: 1342849 Decision Date: 12/26/13 Archive Date: 01/07/14 DOCKET NO. 10-19 382 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to an increased disability rating (or evaluation) in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. J. Dempsey, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from February 1966 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Newington, Connecticut, that, in relevant part, increased the 30 percent disability rating for PTSD to 50 percent, effective January 30, 2009, and denied the claim for TDIU. Although the RO granted a higher 50 percent rating for PTSD, inasmuch as a higher rating is available, and a veteran is presumed to seek the maximum available benefit for a disability, the claim for an increased rating remains viable on appeal. See Breniser v. Shinseki, 25 Vet. App. 64, 79 (2011) (citing AB v. Brown, 6 Vet. App. 35, 38 (1993)). Jurisdiction over this claim is currently with the RO in Hartford, Connecticut. In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the file on the "Virtual VA" system to ensure a complete review of the evidence in this case. FINDINGS OF FACT 1. For the rating period prior to April 20, 2009, the Veteran's PTSD was characterized by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to service-connected PTSD symptoms including sleeping difficulty, paranoia, suicidal ideation, auditory hallucinations, blunted affect, and depressed feelings. 2. For the rating period prior to April 20, 2009, the Veteran's PTSD was not characterized by 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; or memory loss for names of close relatives, own occupation, or own name. 3. For the rating period from April 20, 2009, the Veteran's PTSD has been characterized by occupational and social impairment with reduced reliability and productivity due to symptoms including paranoia, hypervigilant behavior, mild hand tremors, occasional nightmares, withdrawal from social activity, difficulty dealing with stress, and anxiety. 4. For the rating period from April 20, 2009, the Veteran's PTSD has not been characterized by 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); and inability to establish and maintain effective relationships. 5. For the rating period prior to April 20, 2009, the Veteran was unable to secure or maintain substantially gainful employment as a result of service-connected PTSD. 6. For the rating period from April 20, 2009, the Veteran was not unable to secure or follow substantially gainful employment as a result of service-connected PTSD. CONCLUSIONS OF LAW 1. For the rating period prior to April 20, 2009, the criteria for an increased disability rating of 70 percent, but no higher, for PTSD have been more nearly approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 2. For the rating period from April 20, 2009, the criteria for an increased rating in excess of 50 percent for PTSD have not been met or more nearly approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 3. For the rating period prior to April 20, 2009, resolving reasonable doubt in favor of the Veteran, the criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.1, 4.3, 4.15, 4.16, 4.18, 4.19 (2013). 4. For the rating period from April 20, 2009, the criteria for a TDIU have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.1, 4.3, 4.15, 4.16, 4.18, 4.19 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative 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). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). A claim for a TDIU is, in essence, a claim for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Norris v. West, 12 Vet. App. 413, 420 (1999). The Veteran was advised of VA's duties to notify and assist in the development of these claims prior to initial adjudication. A February 2009 letter explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. With regard to the duty to assist, VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the Veteran's claims file includes service treatment records, post-service VA treatment records, Social Security Administration records, VA compensation and pension examinations, and the Veteran's lay statements. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions and findings obtained in this case are adequate. The March 2009 VA PTSD examiner reviewed the electronic medical record, interviewed the Veteran and the Veteran's wife, and observed the Veteran in a clinical setting. The examination report sets forth detailed examination findings in a manner that allows for informed appellate review under applicable VA laws and regulations, and the examiner offered the necessary findings. Therefore, the Board finds that the examinations are sufficient and adequate for rating purposes. As indicated under the facts and circumstances in this case, VA has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal. See Mayfield, 444 F.3d at 1328. Hence, no further notice or assistance is required to fulfill VA's duty to assist the Veteran in the development of these claims. Disability Rating Criteria and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2 (2013), which require the evaluation of the complete medical history of a veteran's condition. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, 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. Id. The schedular criteria for mental disorders, effective as of November 7, 1996, incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130. A rating of 10 percent is warranted for PTSD if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9411. A rating of 30 percent is warranted for PTSD if 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, or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted if it is productive of 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 compete 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 rating, may be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent schedular evaluation contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. 4.130, Diagnostic Code 9411. 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 the 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 his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score 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 DSM-IV at 32 (4th ed. 1994)). A GAF score of 31-40 indicates 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). A GAF score of 41-50 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 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61-70 indicates mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. DSM-IV at 46-47. The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard, 9 Vet. App. at 267; Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue. The GAF score must be considered in light of the actual symptoms of a veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2013). In rendering a decision on appeal, the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. Gilbert, 1 Vet. App. at 55. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. The Board has reviewed all the evidence in the Veteran's claims file, as well as Virtual VA, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the appeal for an increased disability rating for PTSD and entitlement to TDIU. PTSD Disability Rating Analysis Service connection for PTSD was granted in an April 2002 rating decision that assigned a 30 percent disability evaluation, effective October 31, 2000. The Veteran submitted a claim for an increased rating in January 2009, describing himself as the victim of a sexual assault in service and expressing his interest in a reevaluation of his PTSD disability rating. In the September 2009 rating decision on appeal, an increased rating of 50 percent was assigned, effective January 30, 2009. The April 2010 VA Form 9 includes the Veteran's contentions for a rating in excess of 50 percent, including PTSD symptoms such as depression, suicidal ideation, and grief over friends lost in Vietnam. PTSD Rating Period prior to April 20, 2009 After a review of all the evidence, lay and medical, the Board finds that, for the rating period prior to April 20, 2009, the Veteran suffered occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to service-connected PTSD symptoms including sleeping difficulty, paranoia, suicidal ideation, auditory hallucinations, blunted affect, and depressed feelings, which more nearly approximate the criteria for a 70 percent disability rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. Regarding occupational impairment, the evidence weighs favor of finding occupational impairment in most areas due to PTSD symptomatology. VA treatment records from March and April 2008 show that the Veteran was complaining of a relapse in PTSD symptoms over the previous several months, including intrusive thoughts, nightmares, flashbacks, and "recent depression." The Veteran reported hearing voices in his head, as well as auditory hallucinations related to Vietnam. Normal speech, fair insight and judgment, and depressed mood were recorded. Affect was described as sad, constricted, and flat. A mental health treatment note from April 2008 reports that symptoms including paranoia, persecutory hallucinations, and a tendency to isolate and avoid social situations make it difficult for the Veteran to interact effectively with people. The note continued that these symptoms - and others such as difficulty concentrating, anxiety, exaggerated startle response, thoughts of suicide, and poor sleep - would "severely impair his ability to hold a job" and that, as a result, "he is unemployable." A GAF score of 45 was provided in March 2008, followed by a 40 in April 2008. The Veteran underwent a VA PTSD examination in March 2009. The Veteran's wife stated that the Veteran "does not participate in any activities and gets lost frequently." She described the Veteran's sedentary lifestyle and lack of motivation to find employment. The Veteran's wife also stated that the Veteran was not sleeping well and was awakening three to four times per night. The Veteran denied any work or educational activities since February 2007 and stated that he had not worked since being declared "unemployable" at the Northampton VA Medical Center (VAMC). See October 2004 VAMC inpatient discharge note; but see February 2007 VA PTSD examination ("per the Veteran's own report been deemed unemployable by Social Security due to his psychiatric condition"). He reported experiencing nightmares up to four times per week and daily thoughts about hostilities in Vietnam. The Veteran reported symptoms of a foreshortened future and noted that this is an "empty" feeling. He said that he hears voices that instruct him to kill himself on a daily basis. He also reported continued ideation that others, including police officers, are out to get him. The VA examiner noted "significant anhedonia, difficulty concentrating, and interrupted sleep." The Veteran also endorsed "significant psychomotor retardation." He exhibited a depressed mood, blunted affect, somewhat tangential thought processes, avoidance of eye contact with the VA examiner, shabby dress, poor grooming, slurred speech, and signs of cognitive impairment. The VA examiner provided a GAF score of 39 and stated that his level of functioning "appears to be very low." Although the examiner noted that "there is no clear evidence that the Veteran could not work if his symptoms of major depressive disorder and his cognitive difficulties were resolved," the examiner stated that the Veteran was "significantly depressed and does not appear to be able to work, let alone complete his activities of daily living." Following the March 2009 VA PTSD examination, the Veteran enrolled in a VA PTSD therapy group in March 2009. A GAF score of 36 was reported prior to the therapy program, contemporaneous with a clinical assessment of a major depressive episode. At the time of discharge from the PTSD therapy program, the Veteran was less depressed, experienced fewer auditory hallucinations, was sleeping better, and showed improved motivation and energy level. In addition, the discharge note includes a GAF score of 41. Regarding social impairment, the evidence has demonstrated strain on certain relationships; however, the evidence does not show an inability to establish and maintain effective relationships. Despite self-reported strains caused by recent depression, VA treatment records from March 2008 show that the Veteran reported good relationships with his wife, children, and grandchildren. The Veteran also expressed an ability to carry out social functions, although during treatment in April and August 2008, he stated that he avoids crowds. During the March 2009 VA PTSD examination, the Veteran expressed guilt over the strain he has placed on his wife, who described providing "significant care" to the Veteran, including encouraging him emphatically to perform his activities of daily life. The Veteran stated that he had some active friendships; however, he attributed a lack of social activity to his abstinence from substances. VA treatment records from March 2009 further explain how the Veteran complained of having no interest in things, and withdrew from social activities and chores around the house. The Veteran's wife reported that it was difficult to get the Veteran out of bed. The VA clinician provided an assessment of a major depressive episode, and the Veteran subsequently enrolled in the PTSD therapy program discussed above. On review of the evidence, the Board finds that, for the period prior to April 20, 2009, the Veteran's PTSD has been characterized by symptoms including sleeping difficulty, paranoia, suicidal ideation, auditory hallucinations, blunted affect, and depressed feelings. The GAF scores have ranged between 36 and 41. The Veteran's psychiatric symptoms have been relatively consistent during this period, and a 70 percent rating under Diagnostic Code 9411 takes into account occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood - all of which have been exhibited by the Veteran in the period prior to April 20, 2009. 38 C.F.R. § 4.130. The Board has weighed and considered the GAF scores during this period. The GAF scores of 36 and 39 in March 2009 - when the Veteran was undergoing a major depressive episode - and 40 in April 2008 reflect major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. The GAF scores of 45 in March 2008 and 41 in April 2009 suggest serious impairment in social, occupational, or school functioning. When considered alongside the other evidence, the Board finds that these scores and other evidence showing occupational and social impairment are consistent with the 70 percent disability rating criteria of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. All reasonable doubt is resolved in favor of the Veteran to find that a disability rating of 70 percent for Veteran's service-connected PTSD is warranted for the period prior to April 20, 2009. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. The Board also finds that, for the period prior to April 20, 2009, the Veteran's PTSD has not been characterized by 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, as required for a 100 percent disability rating under DC 9411. 38 C.F.R. § 4.130. The lay and medical evidence does not reveal gross impairment in thought processes or communication. VA treatment records from March, August, and December 2008 show that the Veteran displayed normal speech and organized, relevant thoughts. Although the Veteran exhibited somewhat tangential thoughts and slightly slurred speech during the March 2009 VA PTSD examination, such manifestations do not rise to the level of gross impairment contemplated by the 100 percent disability rating. The evidence has also not shown a persistent danger of the Veteran hurting himself or others. At no point during the rating period prior to April 20, 2009 did the Veteran express homicidal ideations. Although the Veteran did express suicidal ideations, he did not show any intention of acting on his suicidal thoughts. With regard to persistent delusions and hallucinations, the Veteran reported hearing voices in his head and exhibited some delusions of persecution. However, the March 2009 VA PTSD examination report explained that "the 'voices' the Veteran reports hearing do not appear to be auditory hallucinations. They appear to be thoughts in his head whose origins he is aware of and can identify." At that time, the Veteran denied any hallucinations other than the voices he heard in his mind. The Veteran's delusions were limited to the belief that others were out to get him. The Veteran was not disoriented to time or place. During the March 2009 VA PTSD examination, the Veteran was oriented generally to person, place and time. Similarly, VA treatment records from March, August, and December 2008 show that the Veteran was alert and oriented to person, place, and time. The Veteran has also not evidenced memory loss for names of close relatives, own occupation, or own name. The Veteran displayed difficulty with short-term memory testing during the March 2009 VA PTSD examination; however, the record does not reflect more severe symptoms such as memory loss for names of close relatives, own occupation, or own name. After consideration of the foregoing, the Board finds that for the period prior to April 20, 2009, the level of occupational and social impairment due to PTSD symptoms does not more nearly approximate the next higher 100 percent rating criteria under Diagnostic Code 9411. Even though the Veteran exhibited some delusions of persecution and passive suicidal ideation, the Veteran's PTSD symptoms, as a whole, are contemplated by the 70 percent rating. See 38 C.F.R. § 4.7 (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). To the extent any higher level of compensation than 70 percent is sought, the preponderance of the evidence is against this claim, and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. PTSD Rating Period from April 20, 2009 On review of the evidence, the Board finds that, for the period from April 20, 2009, the Veteran's PTSD has been characterized by occupational and social impairment with reduced reliability and productivity due to symptoms including paranoia, hypervigilant behavior, mild hand tremors, occasional nightmares, withdrawal from social activity, difficulty dealing with stress, and anxiety consistent with a 50 percent disability rating for PTSD under Diagnostic Code 9411. 38 C.F.R. § 4.130. As discussed above, the Veteran completed a VA PTSD therapy program in April 2009. During the April 20, 2009 follow-up visit to the VAMC following discharge from the PTSD therapy program, the Veteran described the program as an opportunity to "recharge his battery" pertaining to PTSD symptoms and that these symptoms returned to his manageable baseline upon completion of the course. At this time, a VA mental health clinician described PTSD as "mild to [moderate] depending on the triggers." In the same treatment note, the Veteran was reported to have normal speech, euthymic mood, relaxed affect, and organized thoughts. There was no evidence of suicidal or homicidal ideation. A subsequent VA treatment record from January 2010 shows that the Veteran was feeling "more stable" with his symptoms and was "coping much better." The VA mental health clinician noted that the Veteran still displayed difficulty dealing with stress, however, activities of daily life were normal and sleep was lasting between eight and nine hours. The Veteran showed a relaxed affect and euthymic mood. The VA mental health clinician noted that the Veteran complained of mild hand tremors but was not interested in modifying his medication regiment to alleviate those symptoms. An October 2010 VA depression screening suggested no depression, and VA treatment records from the same month reflect normal coping with everyday stress, normal speech, euthymic mood, relaxed affect, good eye contact, organized thoughts, and no evidence of suicidal or homicidal intent. These same mental status traits were demonstrated in VA treatment records from March and April 2011. The Veteran expressed anxiety during VA treatment in June 2011 and displayed an anxious affect. Although auditory hallucinations were no longer present, the Veteran described hypervigilant behavior and paranoia that others were out to get him. These symptoms were reflected again during VA treatment in October 2011, when the Veteran also expressed marriage difficulty and stated that he had no friends. On review of the evidence, the April 20, 2009 VA treatment record - dated from the Veteran's first follow-up visit following discharge from the VA PTSD therapy program - shows that suicidal ideation and auditory hallucinations, two of the most pronounced manifestations of the Veteran's PTSD, had dissipated. Further, VA treatment records from April 20, 2009 until June 2011 consistently show relaxed affect, euthymic mood, and normal functioning in daily life activities. Such improvement was forecasted previously when the March 2009 VA PTSD examiner stated that there was "no clear evidence that the Veteran could not work if his symptoms of major depressive disorder and his cognitive difficulties were resolved." Although symptoms including paranoia, hypervigilant behavior, and withdrawal from social activity began to appear in VA treatment records from June and October 2011, such symptoms are contemplated by the 50 percent disability rating. The Board further finds that, for the period from April 20, 2009, the Veteran's PTSD has not been characterized by 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); and inability to establish and maintain effective relationships. From April 20, 2009, the evidence has demonstrated stability and improved coping, characterized further by a relaxed affect, euthymic mood, and normal functioning in daily life activities. These mental status traits were generally reflected throughout the remainder of the VA treatment records, with the exception of feelings of anxiety and paranoia in June and October 2011. Further, although the Veteran expressed difficulty with his marriage in October 2011, he reported good relationships with his children and grandchildren. Additionally, while the Veteran stated that he had no friends at this time, he had previously indicated that he typically does not socialize because of his abstention from substances. The Veteran displayed symptoms including hypervigilence and paranoia during this period; however, he did not display symptoms such as near-continuous panic or depression that affected his ability to function independently, impaired impulse control, or spatial disorientation. For these reasons, the Board finds that a preponderance of the evidence is against the appeal for a disability rating higher than 50 percent for PTSD for this period, and the claim must be denied. Because the preponderance of the evidence is against the claim for this period, the benefit of the doubt doctrine is not for application for this period. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2013); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested symptoms including sleeping difficulty, paranoia, nightmares, hypervigilant behavior, suicidal ideation, blunted affect, difficulty sleeping, and depressed feelings. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with PTSD, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). TDIU Legal Criteria A claim for a TDIU is, in essence, a claim for an increased rating. See Rice, 22 Vet. App. 447; Norris, 12 Vet. App. at 420. A TDIU claim is an alternative way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. See, e.g., Parker v. Brown, 7 Vet. App. 116, 118 (1994). Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a)(1) (2013). Total ratings are authorized for any disability or combination of disabilities for which the Rating Schedule prescribes a 100 percent evaluation. 38 C.F.R. § 3.340(a)(2). A TDIU may be assigned when the disabled veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). A TDIU may also be assigned pursuant to the procedures set forth in 38 C.F.R. § 4.16(b) for veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). Rating boards are required to submit to the Director, Compensation and Pension Service, for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). The Court has clarified that, where a claimant does not meet the schedular requirements of 4.16(a), the Board has no authority to assign a TDIU rating under 4.16(b) and may only refer the claim to the Compensation and Pension Director for extraschedular consideration. Bowling v. Principi, 15 Vet. App. 1 (2001). Individual unemployability must be determined without regard to any non-service-connected disabilities or a veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a veteran 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 or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. Id. at 361. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a veteran's favor. 38 C.F.R. § 4.3. In Faust v. West, 13 Vet. App. 342 (2000), the U.S. Court of Appeals for Veterans Claims (Court) defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran's earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to TDIU is whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). In evaluating a veteran's employability, consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). Marginal employment, odd-job employment, and employment at half the usual remuneration is not incompatible with a determination of unemployability if the restriction to securing or retaining better employment is due to disability. See 38 C.F.R. § 4.17(a) (2013). TDIU Analysis In this case, the Veteran contends that he had to retire due to his PTSD symptoms. See June 2007 representative letter. The Veteran asserts that he has been out of work since 2004, when he was diagnosed with PTSD at the Northampton VAMC, and that he cannot work because his PTSD medication affects his concentration and makes him drowsy. See April 2010 VA Form 9. Pursuant to the increased rating decision above, the Board has granted a 70 percent rating for service-connected PTSD for the rating period prior to April 20, 2009. The Veteran is not service connected for any other disabilities. The Board finds that for the increased rating period prior to April 20, 2009, the Veteran has met the combined rating percentage criteria at 38 C.F.R. § 4.16(a) for a total disability rating based on individual employability. Therefore, application of a TDIU is appropriate so long as the severity of the Veteran's service-connected disability (PTSD) warrants such a rating during this time period. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The next step is to determine whether the Veteran has been unemployable due to his service-connected PTSD. 38 C.F.R. §§ 3.340(a)(1), 4.15. After a review of all the evidence, lay and medical, the Board finds that, for the rating period prior to April 20, 2009, the weight of the evidence is shows that the Veteran was unemployable due to service-connected PTSD. A VA mental health clinician reported in April 2008 that the Veteran's PTSD symptoms would "severely impair his ability to hold a job" and that as a result, "he is unemployable." Similarly, the March 2009 VA PTSD examiner observed that the Veteran was "significantly depressed and does not appear to be able to work, let alone complete his activities of daily living." When considered alongside the other evidence of record, including the symptoms exhibited by the Veteran during this period, the Board finds that entitlement to TDIU for the period prior to April 20, 2009 is warranted. 38 C.F.R. § 4.16(a). For the rating period from April 20, 2009, the Veteran does not meet the combined rating percentage criteria at 38 C.F.R. § 4.16(a) for consideration of TDIU because, although he has a service-connected disability, the disability rating is not rated at 60 percent or more. For the period from April 20, 2009, service-connected PTSD is rated as 50 percent disabling. Because this is the Veteran's only service-connected disability, the rating must be at least 60 percent to meet the combined rating percentage criteria at 38 C.F.R. § 4.16(a) for consideration of TDIU. Similarly, the Board finds that the Veteran is not unable to secure or follow substantially gainful employment by reason of service-connected PTSD for the rating period from April 20, 2009. The Veteran is a retired maintenance mechanic. During the March 2009 VA PTSD examination, the Veteran denied any work or educational activities since February 2007 and stated that he has not pursued employment because he was declared unemployable at the Northampton VAMC. See October 2004 VAMC inpatient discharge note; but see February 2007 VA PTSD examination ("per the Veteran's own report been deemed unemployable by Social Security due to his psychiatric condition"). However, after completing a VA PTSD examination in March 2009, the VA examiner stated that "there is no clear evidence that the Veteran could not work if his symptoms of major depressive disorder and his cognitive difficulties were resolved." As discussed above, for the period from April 20, 2009, the Veteran was reported to have demonstrated mental health stability and improved coping with PTSD. VA treatment records from that point forward show normal speech, euthymic mood, relevant and organized thoughts, and an ability to manage activities of daily life. Although the Veteran displayed anxious affect during VA treatment in June and October 2011, the evidence of record does not demonstrate an inability to secure or maintain employment due to PTSD symptoms. Further, although the Veteran stated that medication for PTSD makes him drowsy, unable to concentrate, and therefore unable to work, such side effects were not disclosed during VA treatment, when the Veteran complained of side effects including dry mouth, loss of appetite, and weight loss. See, e.g., October 2011 VA treatment record. Thus, although the Veteran is competent to report feeling drowsy and unable to concentrate, the Board finds that the Veteran's April 2010 Form 9 statements regarding his inability to secure or maintain employment due to the side effects of PTSD medication are not credible. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (Board decision properly assigned more probative value to a private hospital record that included lay history that was made for treatment purposes than to subsequent statements made for compensation purposes). In consideration of all the evidence, the Board finds that for the period from April 20, 2009, the weight of the evidence is against finding that the Veteran is unable to secure or follow substantially gainful employment by reason of service-connected PTSD. Although the Veteran is presently not working, the remaining evidence of record does not show that this is because of his PTSD symptoms. Unlike the period prior to April 20, 2009, when VA examiners directly stated that the Veteran was unable to work because of PTSD symptoms, the period from April 20, 2009 is captured more approximately by the March 2009 VA examiner's comment that "there is no clear evidence that the Veteran could not work if his symptoms or major depressive disorder and his cognitive difficulties were resolved." Thus, the Board takes particular note of clinical observations from April 20, 2009, when a VA examiner described mental health stability and improved coping with PTSD; subsequent VA treatment notes that consistently show normal speech, euthymic mood, relevant and organized thoughts, and an ability to manage activities of daily life; and an October 2010 VA depression screen which suggested no depression. As the preponderance of the evidence is against this claim, the benefit of the doubt rule is not for application, and the Board must deny the claim. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER For the rating period prior to April 20, 2009, an increased rating of 70 percent, but not higher, for PTSD is granted; for the rating period from April 20, 2009, an increased rating in excess of 50 percent is denied. For the period prior to April 20, 2009, a TDIU is granted; for the period from April 20, 2009, a TDIU is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs