Citation Nr: 1309331 Decision Date: 03/19/13 Archive Date: 04/01/13 DOCKET NO. 04-43 419 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an increased rating greater than 30 percent prior to April 26, 2010 and greater than 50 percent from April 26, 2010 for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), pain disorder, depressive disorder, and cognitive impairment. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to April 26, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. M. Marcus, Counsel INTRODUCTION The Veteran served on active duty from October 1983 to December 2001. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Veteran had a hearing before the Board in July 2009 and the transcript is of record. The Veteran originally sought an increased rating for his psychiatric disability in March 2003. The claim, along with TDIU, was originally denied in an April 2004 rating decision. During the pendency of this appeal, in a September 2010 rating, the RO granted TDIU and an increased rating for the psychiatric disability to 50 percent, effective April 26, 2010, the date of the most recent VA examination at that time. After the Veteran has perfected his appeal, a subsequent rating decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal. AB v. Brown, 6 Vet. App. 35 (1993). Accordingly, the issues are still properly before the Board here and have been appropriately rephrased above. T The case was brought before the Board in October 2009 and June 2011, at which times the claims were remanded to allow the Agency of Original Jurisdiction (AOJ) to further assist the Veteran in the development of his claims, to include affording him a VA examination. The requested development having been completed, the case is once again before the Board for appellate consideration of the issues on appeal. FINDINGS OF FACT 1. During the entire appellate time frame, the Veteran's psychiatric disability has been diagnosed as mild-to-moderate PTSD, mild cognitive impairment, and severe depression and anxiety, manifested by memory impairment, irritability, delusions, hallucinations, suicidal ideation, homicidal ideation, sleep disturbances, intrusive memories, nightmares, social isolation, some impaired hygiene control, paranoia, inappropriate affect, hypervigilence, and exaggerated startle response all amounting to a serious, but not total, occupational and social impairment. 2. Prior to April 26, 2010, the Veteran was service-connected for a psychiatric disability (rated 70 percent disabling by virtue of this decision), obstructive sleep apnea (rated 50 percent disabling), fibromyalgia (rated 20 percent disabling), recurrent ventral hernia, status post ventral hernia repair (rated 20 percent disabling), hypertension (rated 10 percent disabling), tarsal tunnel syndrome (rated 10 percent disabling), ventral hernia repair scar (rated 10 percent disabling), degenerative disc disease (DDD) of the cervical spine (rated 10 percent disabling), and non-compensable ratings for degenerative joint disease (DJD) of the lumbar spine, DDD of the thoracic spine, plantar fasciitis of the left foot, bilateral pes planus, bilateral hallux valgus, and recurrent epididymitis. 3. Prior to April 26, 2010, the Veteran's combined rating was 90 percent, and the combined effect of his disabilities precluded his ability to obtain substantial and gainful employment. CONCLUSIONS OF LAW 1. For the entire appellate time frame, both prior to and after April 26, 2010, the criteria for an increased rating of 70 percent, but no higher for an acquired psychiatric disability, to include PTSD, pain disorder, depressive disorder, and cognitive impairment, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.326(a), 4.130, Diagnostic Code 9411 (2012). 2. The criteria for TDIU prior to April 26, 2010 have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duty to Assist and Notify The VA has statutory duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). With regard to the TDIU claim, the benefit sought is being granted in full and, therefore, any deficiencies in notice or assistance are considered non-prejudicial. With regard to the psychiatric disability increased rating claim, the notice requirements were met in this case by a pre-adjudication letter sent to the Veteran in May 2003 and post-adjudication letters sent in October 2008 and December 2009. The 2003 letter advised the Veteran of the information necessary to substantiate his claim, and of his and VA's respective obligations for obtaining specified different types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). The 2008 and 2009 letters explained how disability ratings and effective dates are determined and, thereafter, the claim was readjudicated by the agency of original jurisdiction (AOJ) several times, most recently in a December 2012 Supplemental Statement of the Case (SSOC). See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records and Social Security Administration (SSA) disability records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a). The RO provided the Veteran appropriate examinations many times throughout the pendency of this appeal, to include in 2003, 2004, 2008, 2010, 2011, and 2012. Also of record are neuropsychological testing done in 2005 and 2010. These examinations are adequate because they are based on a thorough examination, a description of the Veteran's pertinent medical history, a complete review of the claims folder and appropriate diagnostic tests. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). Thus, the Board finds that VA has satisfied the duty to assist the Veteran and may proceed to consider the merits of the claims. Increased Rating (Psychiatric Disability) Disability ratings are assigned, under a schedule for rating disabilities, based on a comparison of the symptoms found to the criteria in the rating schedule. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability 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. If there is a question as to which evaluation to apply to the Veteran's disability, 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. 38 C.F.R. § 4.7. Staged ratings are appropriate in any increased-rating or initial rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Indeed, in this case, the RO assigned staged ratings here. As will be explained below, the Board finds the severity of the Veteran's psychiatric disability has been consistent through time and, therefore, staged ratings are not appropriate here. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The General Rating Formula for Mental Disorders provides, in pertinent part: 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) . . . . . . . . 30 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 . . . . . . . . . . . . . . . . . . . . . . . 50 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 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 name . . . . . . . . . . . . . . . . . . . . . . . . . 100 38 C.F.R. § 4.130, Diagnostic Code 9411. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" 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 the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. Additionally, a GAF score is often used by treating examiners to reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996). A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). The Veteran's service-connected psychiatric condition is complex consisting of a myriad of diagnoses, to include PTSD, pain disorder, depression, anxiety, and mild cognitive impairment. The Veteran was present during the Oklahoma City bombing during his military service, causing PTSD. He also, however, has numerous physical disabilities, most profoundly fibromyalgia and sleep apnea, which are service connected. His constant pain and sleep disturbances have caused significant psychological affects, to include depression, anxiety, cognitive impairment, and a pain disorder with both psychological and physical components. The medical evidence in this case indicates the Veteran's PTSD alone is of only mild or moderate severity, but the combination of all of the other psychological diagnoses renders his disability more severe. The medical evidence also shows that despite some fluctuations in severity due to life circumstances (e.g., divorce, anniversary date of the Oklahoma City bombing, kids leaving to college), the Veteran's psychiatric disability has been manifested by consistent symptomatology throughout time. The combined symptoms of all his psychological diagnoses have been consistently described as serious, but not total, throughout time. From the time the Veteran filed his claim in March 2003, VA outpatient treatment records, Vet Center records, and VA examination reports reveal GAF scores ranging from 40 to 60. The DSM-IV provides for a GAF rating of 31 to 40 rating for some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). The DSM-IV provides for a GAF rating of 41-50 for 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 rating of 51-60 is assigned for 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). DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). In determining the proper rating for the Veteran at various points of time, the Board relied on GAF scores as assistive and probative evidence, but it is noteworthy that GAF scores are not dispositive and the actually described symptoms in the claims folder were also heavily considered here. See, Massey, 7 Vet. App. at 207. That is, on its face, the GAF score range from 40 to 60 suggests significantly varying severity of the Veteran's psychiatric disability throughout time. In reality, however, the GAF scores throughout time were consistent, and mainly ranged from 50 to 55. The variations below 50 or over 55 occurred at sporadic points in time and usually coincided with a life circumstance (i.e., separation and subsequent reconciliation with his wife, his wife ultimately filing for divorce, his child leaving to college, the anniversary date of the Oklahoma City bombing, etc.). Looking more at the actually described symptoms in the medical records, it is clear the Veteran's psychiatric diagnoses were manifested by serious, but not total, symptoms throughout the appellate time frame. The Veteran filed for an increased rating on March 24, 2003. At that time, VA outpatient treatment records from 2002 to 2003 indicated the Veteran was treated for psychological impairment stemming both from in-service traumatic experiences (i.e., the Oklahoma City bombing), and his chronic pain due to various medical conditions, especially service-connected fibromyalgia and service-connected sleep apnea. He had significant physical medical conditions, which caused pain and sleep disturbances, but the medical evidence indicated the manifestations also had a psychological component. It is important to note that the Veteran's service-connected psychiatric disability rating must not be limited to manifestations stemming from his PTSD, but include manifestations stemming from his pain disorder, depression, and anxiety secondary to other service-connected physical disabilities. After filing for an increased rating, the Veteran was first afforded a VA examination in July 2003. The Veteran was also afforded VA examinations in January 2004, June 2008, April 2010, August 2011, and October 2012. The Veteran also receives regular group therapy from the Vet Center, which provided psychological assessments from 2003 to 2012 in support of the Veteran's appeal. VA outpatient treatment records indicate regular medical treatment for his psychiatric disability as well as neuropsychological testing completed various times throughout the appellate time frame. Within these VA examinations, Vet Center assessments, neuropsychological testing, and VA outpatient treatment records, the Board notes several consistencies. Initially, prior to the Oklahoma City bombing, the Veteran worked in the Army as a truck driver. Thereafter, because of his psychological struggles, memory impairment, and physical disabilities, the Army reassigned the Veteran to work as a clerk/receptionist for the last year of his service. He was separated from the military in December 2001 and has been unsuccessful in finding longstanding employment ever since. In July 2003, the VA examiner noted that the Veteran's psychiatric disability was manifested by short-term memory deficits, significantly lower than average social comprehension, mild dementia, nightmares, recurrent memories, a dislike for crowds, significant depression and anxiety, and intrusive thoughts. At that time, the Veteran was alert and oriented on all planes, exhibited appropriate grooming, denied suicidal ideation, homicidal ideation, hallucinations, delusions or any other psychosis. The examiner also noted the Veteran's lengthy marriage to a woman he had known since junior high school, and a good relationship with his two sons. It is also noteworthy that the examiner noticed an inappropriate affect. Specifically, the Veteran would smile or laugh while describing traumatic events or painful manifestations. Even so, the Veteran was found able to perform most activities of daily living. Overall, the examiner assigned the Veteran a GAF score of 50, for serious impairment of social and occupational functioning. The January 2004 VA examiner addressed the Veteran's employability, finding his PTSD to limit his work, but not preclude employment. It is noteworthy that subsequent VA outpatient treatment records indicate the Veteran was very nervous during the 2003 VA examination and did not discuss all the symptoms he had. In 2004 VA outpatient treatment records, the Veteran indicated he is paranoid, constantly feeling as though he is being followed. VA outpatient treatment records dated in 2005 indicate symptoms of depression, hallucinations, memory impairment, nightmares, sleep disturbances, and extreme anxiety. The Veteran was afforded VA neuropsychological testing in May 2005 where the Veteran was found on exam to be extremely, severely depressed with severe anxiety. The test noted the Veteran's social isolation, seeing things crawling, forgetfulness, poor eating habits, and hearing noises. The examiner noted, however, that part of the Veteran's impairment stemmed from a pain disorder with both psychological and general medical components. Vet Center assessments dated in 2004, 2005, and 2007 also paint a vastly different picture of the Veteran's disability compared with the July 2003 VA examiner's findings. Therein, the readjustment counselor reported the Veteran suffered from "extreme" anxiety and depression, disorientation, and short-term memory impairment. The Veteran was noted to have difficulty comprehending commands and exhibited hallucinations, both auditory and visual. He had a history of suicidal ideation and general paranoia. The counselor also reported sleep disturbances and marital discord. In fact, it was his extreme aggressive behavior during his sleep that caused strain on his marriage. The counselor also reported an inability to perform activities of daily living, such as driving. While the Veteran previously denied panic attacks to the 2003 VA examiner, the Vet Center counselor reported ongoing panic attacks, complete social isolation, and an overall serious impairment. The counselor further reported substance abuse (alcohol) used as a "sleep aid." The Vet Center counselor indicated a GAF score of 50. (See, e.g., Vet Center Assessment April 2007). The Veteran was afforded an additional VA examination in June 2008. At that time, the VA examiner noted the Veteran had been married to his wife for over 25 years and that they get along well. He also indicated he got along well with his two sons, but otherwise had no social interaction with anyone. The Veteran denied suicidal ideation, but at that time indicated homicidal ideation, due to paranoia of people following him. He was casually dressed, with disheveled clothes, but otherwise good hygiene. Similar to 2003, this examiner noted the Veteran's inappropriate affect with extremely slow speech and inappropriately smiling or laughing while describing traumatic events or symptoms. The Veteran was oriented on all four planes, but his thought process was illogical. The examiner noted delusions, but no hallucinations. The Veteran also indicated insomnia and panic attacks once every two to three weeks. The Veteran's ability to perform activities of daily living was noted as "moderately impaired." He Veteran again was found on exam to have mild memory impairment, intrusive memories, avoidance tendencies, sleep disturbances, anger, hypervigilence, exaggerated startle responses, concentration problems, and irritability. The examiner assigned a GAF score of 60, noting that the Veteran's PTSD was not the number one factor of his disability or unemployability. Rather, the examiner at that time also diagnosed the Veteran with a schizoid personality disorder finding that to be the number one factor in his unemployability and overall disability picture. In light of the examiner's narrative, it is unclear whether the GAF score assigned was representing solely his functioning based on PTSD symptoms rather than his total psychiatric picture. VA outpatient treatment records from 2008 to 2009 again show a vastly different disability picture. In March 2008, the Veteran was seen complaining of increased symptoms because of the pending anniversary date of the Oklahoma City bombing. The VA physician assigned a GAF score of 48 at that time, indicating his symptoms increase every year in the April time frame because of the anniversary date of the bombing. VA outpatient treatment records in 2009, however, show GAF scores ranging from 40 to 50. At that time, the Veteran was undergoing familial discord. He and his wife had separated, and then she subsequently filed for divorce. At the same time, his youngest son went off to college. The Veteran was then afforded a new VA examination in April 2010 where the Veteran complained of depression, suicidal ideation, daily anxiety, memory loss, and sleep disturbances. At that time, the Veteran reported being previously separated from his wife for 6 to 8 months, but now "trying to patch things up." He also reported an alteration he got into at his son's college campus with a security guard. He again indicated a good relationship with his sons, but otherwise no other social interaction. The examiner, similar to other examiners, noted his slow, slurred speech, and inappropriate affect. The Veteran was dysphoric and suspicious, but otherwise oriented on all planes. The Veteran also reported auditory and visual hallucinations, but no panic attacks. His personal hygiene was satisfactory, but the examiner noted the Veteran reported needing to be reminded to keep up his hygiene and other activities of daily living, such as eating. The examiner also noted moderately impaired memory, sleep problems, irritability, anger, difficulty concentrating, hypervigilence, and exaggerated startle response. On the other hand, the examiner doubted the veracity of some of the symptoms indicating the Veteran had a tendency to exaggerate. He reported working at some fast food joints, but not currently working now. The examiner diagnosed the Veteran with mild-to-moderate PTSD, pain disorder, and schizoid personality disorder assigning a GAF score of 55. The examiner specifically found the Veteran to not exhibit total occupational and social functioning. Rather, the Veteran's impairment stems mainly from his subjective pain and personality disorder. In contrast, his PTSD causes mild impairment. A May 2010 neuropsychological testing report reveals "mild cognitive impairment" causing memory impairment, and some other social interaction impairment. The Board finds noteworthy within this report, the Veteran reported being married to his wife for 27 years, with a successful reconciliation. The Veteran was afforded another VA examination in August 2011 where, at that time, the Veteran was again separated from his wife. Upon completion of clinical testing, the Veteran was diagnosed with mild cognitive impairment secondary to emotional diagnoses or concomitants, such as PTSD, anxiety, depression, schizoid personality, and chronic pain (with both psychological and general medical components). The examiner clarified that the Veteran did not have a cognitive disorder, but rather a mild cognitive impairment stemming from his other psychiatric diagnoses. The Veteran was most recently afforded a VA examination in October 2012. At that time, the Veteran reported currently going through a divorce after a four month separation. He still maintained a good relationship with his sons and went to church twice a week. He resides with his sister, and other than his family, he does not socially interact with anyone. With regard to employment, the Veteran again indicated he attempted to work. He tried driving the church van and volunteering at a VA facility filing records. At that time, he reported unemployment since 2010. The 2012 examiner noted manifestations of recurrent memories, nightmares, avoidance of people and activities, difficulty sleeping, irritability, anger, hypervigilence, exaggerated startle response, depression, anxiety, suspicious, panic attacks weekly or less, mild memory loss, and a loss of motivation. The examiner diagnosed the Veteran with PTSD and major depressive disorder (MDD) assigning a GAF score of 55. Significantly, at that time, the examiner found no evidence of a personality disorder. In short, all medical records throughout time show some amount of consistent symptoms to include memory impairment, difficulty understanding commands, social isolation (aside from his family), serious depression, anxiety, sleep disturbances, nightmares, and intrusive thoughts. The July 2003, June 2008, and April 2010 VA examiners all note how the Veteran would inappropriately smile or laugh while describing traumatic events or problematic symptoms. Inconsistently, the Veteran was also reported to having suicidal ideation, homicidal ideation, hallucinations, delusions, paranoia and panic attacks. The Board finds, however, that while these symptoms were not always noted by every examiner, they were significantly noted throughout time by many VA physicians. In fact, the Veteran reported in 2004 that he was nervous during his 2003 examination, which at least partially explains the omission at that time. It is also clear the Veteran's GAF scores mostly ranged in the 50 to 55 area with short-lived fluctuations as low as 40 (or as high as 60) due to life circumstances. In 2009, for example, the Veteran's GAF scores were reported in the VA outpatient treatment records at 40, 48, and 49 due to the Veteran's separation from his wife, the Oklahoma City Bombing anniversary date, and his son leaving for college. The 2008 VA examiner assigned a GAF score of 60, slightly higher than others, but as noted above, it is unclear whether this GAF score only takes into account manifestations of the Veteran's PTSD (versus a combination of all his psychiatric diagnoses). Indeed, many of the examiners diagnosed the Veteran with a myriad of disabilities, to include PTSD, anxiety, depression, pain disorder, mild cognitive impairment, and personality disorder. In contrast, the narrative provided by the examiners more often focused on the Veteran's impairment solely caused by PTSD. Again, the Veteran is service connected for his entire psychiatric disability, to include PTSD, anxiety, depression, and pain disorder with cognitive impairment. Many of the examiners described the Veteran's PTSD as "mild" or "mild to moderate." Most examiners, however, described the Veteran's anxiety and depression as "severe." In light of the medical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds his aggregate psychiatric disability most nearly fits the criteria for a 70 percent rating, but no higher. At all times, the Veteran exhibited memory impairment with difficulty understanding commands, serious disturbances in mood and motivation, sleep disturbances, and inappropriate affect. The medical evidence also indicates manifestations of homicidal and suicidal ideation, delusions, hallucinations, panic attacks, illogical speech, and social isolation. While these symptoms are inconsistently reported, the Board finds the symptoms are noted in the records throughout the appellate time frame. In contrast, no medical professional has found the Veteran's acquired psychiatric disability alone renders him totally disabled. In fact, every VA examiner opined to the contrary. While the Veteran has significant limitations due to his psychiatric diagnoses, his unemployability is a combined consequence of both his physical and psychiatric limitations. The Veteran also does not have the manifestations associated with a 100 percent rating. Examiners have at times reported delusions or hallucinations, but clearly indicate they are not persistent delusions or hallucinations. While he has a history of suicidal and homicidal ideation, the Veteran is not in persistent danger of hurting himself or others. In fact, the Veteran has never attempted suicide nor does he have a history of violence. The Veteran is oriented to time and place, and his memory impairment has consistently been described as "mild." For these reasons, a 100 percent rating is not supported by the record at any time period. Rather, the Board concludes that since the filing of his increased rating claim on March 24, 2003, the Veteran's acquired psychiatric disability exhibited symptoms most closely resembling the 70 percent criteria, but no higher. Extraschedular Considerations The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected psychiatric disability. The Veteran's disability is manifested by impairment in social and occupational functioning. The rating criteria contemplate these impairments; hence, referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). TDIU The Veteran contends he is unable to maintain substantial gainful employment due to a combination of his service-connected disabilities. He was awarded TDIU, effective April 26, 2010, but he claims his unemployability should date back to the date of his claim (March 24, 2003). In light of the increased rating granted here, prior to April 26, 2010, the Veteran's service-connected disabilities and ratings were as follows: a psychiatric disability (rated 70 percent disabling by virtue of this decision), obstructive sleep apnea (rated 50 percent disabling), fibromyalgia (rated 20 percent disabling), recurrent ventral hernia, status post ventral hernia repair (rated 20 percent disabling), hypertension (rated 10 percent disabling), tarsal tunnel syndrome (rated 10 percent disabling), ventral hernia repair scar (rated 10 percent disabling), degenerative disc disease (DDD) of the cervical spine (rated 10 percent disabling), and non-compensable ratings for degenerative joint disease (DJD) of the lumbar spine, DDD of the thoracic spine, plantar fasciitis of the left foot, bilateral pes planus, bilateral hallux valgus, and recurrent epididymitis. He now has a 90 percent combined rating prior to April 26, 2010. See 38 C.F.R. § 4.25. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Clearly the Veteran meets the schedular criteria for consideration of unemployability under 38 C.F.R. § 4.16(a) prior to April 26, 2010. The only remaining question in this case is whether the Veteran was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities prior to April 26, 2010. In determining unemployability status, the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the above percentages for service-connected disabilities are met and in the judgment of the rating agency such service-connected disabilities render the veteran unemployable. 38 C.F.R. § 4.16(a). His age, additionally, cannot be taken into account in evaluating his individual unemployability status. See, e.g., Van Hoose v. Brown, 4 Vet. App. 361, 363 (1995). The Veteran has not had any substantial employment since his retirement from the Army in 2001. He indicates he worked as a truck driver for the Army, but was reassigned as a receptionist for his final year of service due to physical and psychiatric disabilities. After service, the Veteran testified before the Board that he attempted to find employment. He tried to work as a school bus driver in April 2002, but failed the physical. He indicated he applied for receptionist positions, to include at the VA Hospital in March 2003, but was never hired. He further indicated in various examinations, that he would have short-lived jobs at "fast food joints." He most recently indicated to the October 2012 VA examiner that he has not worked at all since 2010. In 2011, he reported a history of attending two years of college, and receiving an associate's degree in general studies. The Veteran is receiving SSA disability benefits. VA outpatient treatment records, Vet Center assessments, and VA examinations throughout the pendency of this appeal clearly reflect the Veteran has serious occupational impairments due to his service-connected disabilities. In contrast, in January 2004, the examiner opined that the Veteran's PTSD "limits his work," but none of the other physical problems appear severe enough to prevent him from working. The examiner found the Veteran would have trouble with heavy manual labor, but could perform sedentary, office-type work. The examiner, however, did not clearly proffer an opinion as to whether the Veteran was unemployable due to an aggregate affect of both his physical and mental service-connected disabilities. Similarly, in June 2008, the Veteran was afforded a VA examination where the examiner found the Veteran's PTSD not severe enough to prevent employment. The examiner found the Veteran able to perform sedentary employment. Rather, the examiner found the Veteran's personality disorder to be the number one factor of his unemployability. The Board finds this opinion problematic as well. The examiner did not address whether the Veteran was unemployable due to the aggregate affect of all service-connected disabilities. Also compelling, the most recent 2012 VA examiner did not find evidence of this personality disorder. The Veteran was afforded a VA examination on April 26, 2010 where the examiner concluded the Veteran's activities of daily living, to include employment, are negatively impacted by the combined effects of his medical/physical problems, his subjective pain, and his personality disorder. Based on this opinion, the RO awarded TDIU, effective April 26, 2010. The Board finds, however, that medical evidence prior to April 26, 2010 supports the same conclusion. Although no medical professional specifically addressed the Veteran's employability based on the aggregate effect of all his service-connected disabilities, the medical evidence indicates the Veteran's "serious" occupational and social impairment stem from both the physical manifestations of his service-connected disabilities, and his emotional perception of those manifestations. In the July 2003 VA examination report, for example, the examiner noted the Veteran's extreme fixation on his bodily symptoms seriously impacting his social and occupational functioning. The Veteran's diagnosed "pain disorder" throughout time has been described as having both a physical/general medical component and a psychological component. In short, prior to April 26, 2010, no medical professional specifically addressed the pertinent inquiry of whether the aggregate affect of all the Veteran's service-connected disabilities, both physical and psychological, rendered him unemployable. Rather, the medical opinions of record limit the inquiry to either the psychiatric component or the physical component. The medical evidence as a whole, however, suggests that the aggregate affect of his disabilities caused "serious" occupational impairment. The Veteran also testified as to his long-standing problems finding substantial, long-term employment. The evidence is, at the very least, in relative equipoise. As such, the Veteran is entitled to the benefit of the doubt. Thus, a total disability rating for compensation purposes based on individual unemployability prior to April 26, 2010 is warranted. ORDER Entitlement to an increased rating of 70 percent, effective March 24, 2003 (date of the increased rating claim), but no higher, for an acquired psychiatric disability, to include PTSD, pain disorder, depressive disorder, and cognitive impairment is granted subject to the laws and regulations governing monetary awards. Entitlement to TDIU prior to April 26, 2010, effective March 24, 2003 (date of the increased rating claim), is granted subject to the laws and regulations governing monetary awards. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs