Citation Nr: 1342406 Decision Date: 12/23/13 Archive Date: 12/31/13 DOCKET NO. 11-00 873 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial disability evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Wade R. Bosley, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Budd, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1965 to December 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from August 2008 (PTSD) and December 2008 (TDIU) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In August 2012, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. FINDINGS OF FACT 1. During the appeal period the Veteran's PTSD has been manifested by symptoms productive of functional impairment comparable to occupational and social impairment with deficiencies in most areas. 2. The most probative evidence of record demonstrates that the Veteran's service-connected disabilities preclude him from securing or following a substantially gainful occupation consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. Throughout the appeal period, the criteria for an evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2013). REASONS AND BASES FOR FINDING AND CONCLUSIONS Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. With respect to the TDIU claim, the Board is granting in full the benefit sought on appeal. Accordingly, any error committed with respect to either the duty to notify or the duty to assist in that claim is harmless and will not be further discussed. Once service connection has been granted, the context in which the claim initially arose, the claim has been substantiated; therefore, additional VCAA notice under § 5103(a) is not required because the initial intended purpose of the notice has been fulfilled, so any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Rather, thereafter, once a notice of disagreement (NOD) has been filed, for example contesting a downstream issue such as the initial rating assigned for the disability, only the notice requirements for a rating decision and SOC described in 38 U.S.C. §§ 5104 and 7105 control as to the further communications with the Veteran, including as to what evidence is necessary to establish a more favorable decision with respect to downstream elements of the claim. 38 C.F.R. § 3.159(b)(3). The RO has provided the Veteran the required SOC discussing the reasons and bases for not assigning a higher initial rating and citing the applicable statutes and regulations. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton, 9 Vet. App. 553 (1996). The Veteran's service treatment records and post service VA treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The record does not indicate that there are any private treatment records relevant to these claims. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration (SSA). 38 C.F.R. § 3.159(c)(2). VA examinations were conducted in July 2008 and January 2011. The Veteran has not argued, and the record does not reflect, that the examinations were inadequate for purposes of determining entitlement to an increased rating for PTSD. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examiners reviewed the medical record or took the Veteran's history, conducted psychiatric examination of the Veteran, and discussed the functional impairment resulting from the Veteran's disability. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Increased Rating Criteria Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. §4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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. In determining the present level of a disability for an initial increased evaluation claim, staged ratings must be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. When evaluating a mental disorder, the rating is to be based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. The extent of social impairment must be considered, but a rating may not be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126. Age may not be considered as a factor in evaluating a service-connected disability. 38 C.F.R. § 4.19. A 70 percent evaluation is warranted if the evidence establishes there is 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); or inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted if the evidence establishes there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting oneself 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. Id. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (4th ed. 1994). A GAF score ranging from 61 to 70 reflects the presence of some mild symptoms (e.g., depressed mood or mild insomnia) or some difficulties in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally indicates one is functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51 to 60 is illustrative of 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 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Diagnostic and Statistical Manual of Mental Disorders, 46-47 (4th ed. 1994); 38 C.F.R. § 4.130. Facts The August 2008 rating decision on appeal established service connection for PTSD effective from March 31, 2008. As such, the rating period for consideration on appeal is from March 31, 2008. However, as noted above, medical history is for consideration in evaluating a service-connected disability. The Board has received relevant lay testimony from the Veteran himself as well as his sister and two friends. One of those friends, S.S., wrote a statement dated April 2008 in which he described that Veteran as always alert and cautious, and wrote that the Veteran "has a lot of friendly acquaintances but I am not sure he has any real close friends. I might be one of his closest friends." He wrote that the Veteran does not share his emotions, but that he thinks he "feels insecure and he has helplessness feelings," with a short temper. He reported that the Veteran avoids crowds, isolates, and "never seemed to be able to stay in a relationship very long." The Veteran's letter, dated May 2008, describes the Veteran as avoiding crowds. He wrote that he does not go out to eat very often, and when he does, he insists on sitting in a corner with his back to the wall, so that he feels protected. He also tries to sit by a window so he can watch for potential hazards outside. He wrote that he could only trust a few people. He described periods of anxiety, and his practice of avoiding anything to do with Vietnam or war on television. He related that he experiences nightmares about Vietnam 2-3 times a week, and that he experiences flashbacks daily. He wrote that he was often depressed, and that he would try to combat depression by staying busy, explaining "[i]f my mind and body rests, my mind will be back in Vietnam." He wrote that he keeps the doors and windows of his house locked, and that he will check the locks on his door 2-3 times a night, at times leaning a chair underneath the door knob. He also keeps the drapes closed at all times and keeps a pistol beside his bed. He described his long term and short term memory as poor, and wrote that loud unexpected noises startle him easily. He described difficulty in going to sleep, and an inability to sleep more than two hours at a time, which was reminiscent of the practice while on guard duty in Vietnam. He described himself as a loner who isolates himself and is unable to complete tasks. He noted suicidal thoughts at least once a week, with a plan of using a gun in the woods. He explained inexplicable disorientation in which he does not know where he is or what he is doing, and described himself as cold, aloof, and at times uncaring. In a May 2008 statement, another friend of the Veteran, D. M., described the Veteran as a suspicious, anti-social loner who isolates himself and does not like crowds. She indicated that he experiences an anxiety attack if he is around a lot of people. She described an incident where he went to his sister's home for Christmas, but quickly left because he was unable to deal with the people and noise. She described spells "where he might sit or lie and just stare into space" for up to three days in succession. She wrote that he did not trust anyone completely but her. She also described him as "a fanatic about avoiding germs," carrying anti-bacterial lotion with him at all times and wearing gloves when he prepares his own food, as well as asking her to wear gloves if she prepares food for him. She described him as dousing food "with anti-bacterial stuff of some kind before he will touch or eat it." She wrote that "[s]ince [the Veteran] retired he has more time to think and the more he mentions [Vietnam]." She described him as having flashbacks 2-3 times a day, being unable to concentrate, and having a short term memory so bad that he "has to make a note of everything in order for him to remember," with restrictions about what things are allowed on the list. She wrote about the Veteran's difficulty sleeping. She described him as emotionally defensive, and irritable "probably 50 [percent] of the time," with severe mood swings. She described him as keeping the blinds on his house closed and using small lights at night because "he does not want to be a target for anyone outside." She wrote that he did not like going to restaurants, and described his practice of sitting by a window or facing the door. She described him as becoming completely disoriented "an average of once every week or two." The record also contains a May 2008 letter from the Veteran's sister, who discussed the Veteran's excessive drinking and poor hygiene after returning from Vietnam, as well as an incident where he pulled up in a car beside her when she was walking with friends and yelled at her. She wrote that he never wanted to work, and hated his job. She described a period of homelessness in the 1980s. She described the Veteran as an "uncaring person" without sympathy, and with trouble concentrating. She also described the incident where he came to spend Christmas with their family at her house, and then left because he could not stand the noise. She reported that he seemed to have only two friends. She wrote that "[i]f you are not tuned into 'his frequency' [you] will often times find him staring off into space." She also wrote that she only sees the Veteran "maybe three times a year." A VA psychological examination was held in July 2008. At this examination, the Veteran reported daily alcohol abuse. The Veteran stated that he was engaged, but had few social connections outside of that relationship. The examiner described the Veteran as neatly groomed and appropriately dressed, with spontaneous speech; a cooperative, friendly, relaxed and attentive attitude; having normal affect; and having an anxious mood. The Veteran reported poor sleep, with nightmares related to trauma, and frequently awakening. The examiner indicated that the Veteran did not have inappropriate behavior, but that he had obsessive/ritualistic behavior in that he showers three times per day due to his concern with germs, which the Veteran felt was related to being dirty in Vietnam. The Veteran denied panic attacks or homicidal thoughts, but noted passive suicidal ideation without plan or intent. He also reported a suicide attempt in the late 1980s. The examiner wrote that the Veteran "notes his temper is currently under control but previously he became angry at levels beyond what was called for. Symptoms have worsened since the patient retired." The Veteran noted "an extreme need to feel safe and cannot relax without alcohol. [H]e notes that he has difficulties sleeping and avoids a range of things which might recall Vietnam including being dirty or feeling warm during the evening. [H]e notes difficulties forming close relationships with others." The Veteran also reported few social contacts and difficulties forming romantic attachments. The Veteran's PTSD symptoms included recurrent and intrusive distressing recollections of an in-service traumatic event; intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; restricted range of affect; difficulty falling or staying asleep; hypervigilance; and exaggerated startle response. The examiner noted that the Veteran had good impulse control, the ability to maintain minimum personal hygiene, and no problem with activities of daily living. The examiner described the Veteran's memory as normal. The examiner indicated that the Veteran's disturbance caused clinically significant distress or impairment in social, occupational or other important areas of functioning, and described the symptoms as being at a moderate level. The examiner noted that the symptoms occurred on a daily basis and began after exposure to trauma. When discussing employment, the Veteran indicated that he took early retirement in March 2007, and that "[t]here were conflicts with others." The Veteran was described as a "workaholic." The Veteran indicated difficulties adapting to retirement, and that his symptoms had worsened since he retired. The examiner indicated that there was no total occupation and social impairment due to PTSD, but that the Veteran's PTSD did result in deficiencies in family relationships and mood, but not judgment, thinking, or work, noting that the Veteran "tended to use work to manage anxiety in the past and subsequently is more distressed since retiring." The examiner assigned the Veteran a GAF score of 51. The Board has received a completed Request for Employment Information form dated January 2010, indicating that the Veteran retired from his position as a sales representative in March 2007. The Veteran's January 2010 Application for Increased Compensation Based on Unemployability also indicates that he retired in March 2007. On this application, the Veteran checked the box indicating that he did not leave his last job because of his disability, but later wrote, "my PTSD symptoms escalated to the point where my paranoia, concentration problems, daily flashbacks, anxiety, [and] extreme hypervigilance made it impossible to keep working and when I had a chance, I got out. I was able to last as long as I did because my job allowed me to isolate when I needed to." Another VA psychological examination was scheduled for January 2011, but the Veteran did not report to it. He later explained in an April 2012 Form 9 appeal that he had been unable to attend because the scheduling of the appointment required him to leave his home when it was dark outside. The Veteran was unable to do this due to a fear of driving in the dark, as well as being unable to "stand the stress of an early morning fight for parking places." His VA examination was rescheduled for later that month. At this examination, the Veteran described having one friendship, but no relationship with his family. The Veteran stated that he "[s]tays home most of the time, smokes, drinks, watches TV." He also indicated that he was able to go grocery shopping, and that he liked going to "antique places." He denied a history of suicide attempts, and then denied problematic effects of his alcohol use. The examiner described the Veteran as casually dressed, with cooperative attitude and constricted affect. His mood was depressed, and he was easily distracted. He was unable to do serial sevens. He had no delusions, his thought process and content were unremarkable, and he understood the outcome of behavior. The Veteran reported sleeping in two hour increments during the night, and feeling tired most days as a result. The examiner indicated that the Veteran had inappropriate behavior, that he did not have obsessive/ritualistic behavior, and that he did not have panic attacks, homicidal thoughts, or suicidal thoughts. The examiner described the Veteran's impulse control as fair and his immediate memory as mildly impaired. The examiner indicated that the Veteran was able to maintain minimum personal hygiene, and that there was no problem with the activities of daily living. The Veteran's PTSD symptoms were recurrent and intrusive distressing recollections of a traumatic event; recurring distressing dreams of the event; acting or feeling as if the traumatic event were recurring; efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that aroused recollections of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; restricted affect; sense of foreshortened future; difficulty falling or staying asleep; irritability or outburst of anger; difficulty concentrating; and hypervigilance. The Veteran's symptoms were described as chronic for several years and moderate in severity. The Veteran indicated that he had retired in 2006, and stated that the cause of his retirement was that he was eligible by age or duration of work. The examiner wrote that the Veteran's "PTSD symptoms impair occupational functioning via his inability to relate effectively with others, poor concentration, irritability, difficulty sleeping, and experiencing flashbacks and intrusive thoughts." The examiner also wrote that given the Veteran's lack of treatment participation at this time, the prognosis for improvement of the Veteran's psychiatric condition and impairments in functional status were low. However, the examiner also indicated that there was no total occupational and social impairment due to PTSD. The examiner reported that the Veteran's PTSD symptoms did result in deficiencies in thinking due to intrusive thoughts about the war and flashbacks, family relations as indicated by his social isolation, work as his occupational functioning was impaired by his inability to relate effectively with others, poor concentration, irritability, difficulty sleeping, and flashbacks/intrusive thoughts, as well as his mood due to depression. The examiner indicated that the Veteran's judgment was not impaired. The examiner gave the Veteran a GAF score of 52. A March 2012 VA treatment note indicates that the Veteran reported depression "mostly just for the past few days" because the anniversary of his mother's death was coming up. The Veteran described himself as having three close friends, and stated that he felt like he needed to be healthy in order "be there for them." He said he slept for about two hours at night, "just like he did in Vietnam." He reported nightmares and having suicidal thoughts all his life, but denied plan or intent, stating that "he knows he has a purpose here." He said that he drank five beers each night to help him sleep, which he had decreased from twelve. The Veteran indicated that he wanted to "give it a few days" without making further use of VA services because he usually can "come out of this by myself." In an April 2012 follow-up the Veteran reported feeling better, and that he had "pretty much gotten past" the issues with his mother's death. He denied suicidal or homicidal thoughts, and denied needing additional services. The Board has received a July 2012 vocational evaluation regarding the Veteran. The Veteran's representative's August 2012 accompanying statement may be construed as waiver of RO consideration of that additional evidence. The evaluator indicated that he had reviewed the Veteran's claims file. The evaluator wrote that his first attempts to contact the Veteran were not returned for several days, before he replied to an email "stating that he was very down and asking if [the evaluator] would wait for a day or two before contacting him again." The evaluator did so, and then was able to successfully speak with the Veteran. The evaluation indicates that the Veteran has a high school education, and that he also took some college courses in time study. The evaluator described the Veteran's employment as "on and off" and wrote that the Veteran "sold beer from the distributor by any means necessary, from cleaning toilets to taking owners out to lunch or social events." The Veteran trained employees and "won awards from Coors for the best service department in the nation." The evaluator described the Veteran as a workaholic who "works 24/7 to keep his mind off the events from his combat experience." The Veteran's employment became less demanding as the employees he had trained became more competent, and as a result the Veteran "just sat around and did nothing," which the evaluator opined was "not equivalent to entry or competitive work" and "was not suitable for [the Veteran], because any idleness brought the memories flooding back." The evaluator wrote that the Veteran stopped working around March 2008 and stated that the Veteran "had actually not been working a realistic job for at least a year and half before [March 2008]." The evaluator wrote that training employees became harder as his patience decreased and his intrusive memories became worse. The evaluator indicated that the Veteran "isolates himself for days at a time," that he "cannot focus for the length of time needed to complete even simple tasks," and that the Veteran "is always 'on edge.'" The evaluator ultimately concluded that the Veteran was "unable to perform any work at all because of his lack of ability to focus and concentrate for extended periods, or to be able to deal in any meaningful way with employees or members of the public." He wrote that it was at least as likely as not that the Veteran had been unable to secure or follow a substantially gainful occupation since at least March 2008. In the August 2012 Board hearing transcript, the Veteran stated that he could not drive in the dark, and that he was "afraid of the dark." The Veteran explained that in his position as a beer sales representative, he was able to work hours that let him avoid driving in the dark. The Veteran indicated that in the last year or so of his employment, his work, which included training other employees, became more difficult as his patience grew less and his irritability and intrusive memories increased. He described himself as staying in a remote office while the employees he had trained went out to do the sales and service, and signing off on their paperwork after they returned. The Veteran said that he would wash himself in a basin in one of the washrooms at work in order to accommodate his need for cleanliness. The Veteran explained that he had difficulty in dealing with "the public," and explained that he "had a lot of complaints called on [him]." He would stay away from others because of difficulty with anger. He also indicated that he coped with PTSD by throwing himself into work "24/7." Ultimately, the Veteran explained that he retired in 2008 because he accepted a buyout that was offered to him but not to any other employees. The company told him that they were doing away with his position. The Veteran also stated that he was not getting along with people in upper management. The Veteran explained that after retiring he spent most of his time in his apartment, and that he will sometimes go two or three days without leaving his home because he feels safer inside. He stated that he did not have any close friends. He described a close relationship with his cats. He said that he does not know any of his neighbors, and endorsed that he has daily flashbacks and at times simply sits or lies down and stares into space. He also explained that he does not often answer his telephone because he has "to get up enough nerve" to do so. He explained that he could only sleep for a few hours a night. He also stated that he goes to the grocery store when it is not crowded because when he goes to the store he is "terrified." When asked about whether his hearing loss affected his ability to work, the Veteran said that at times he does not hear everything that is said to him. The Veteran stated that he cannot wear his hearing aids in large buildings because "it's too much noise coming in," and around a lot of people "I hear way too much that I don't want to hear." Increased Rating Analysis The Board notes that the facts in this case contain inconsistencies. The date of the Veteran's retirement seems to migrate between 2006 and 2008. The Veteran has described himself as keeping his PTSD symptoms at bay by throwing himself completely into his work while his sister described him as hating to work. The Veteran and his friend D.M. both described the Veteran as fixated on cleanliness, while his sister described him as having poor hygiene. Therefore, it falls on the Board to attempt to discern an accurate picture of the Veteran's PTSD symptoms in spite of these contradictions. The Board notes that as the Veteran's sister has testified that she only sees the Veteran a few times a year, the testimony of the Veteran and his friend D.M., who sees him more frequently, is more probative. The Board also notes that the Veteran's sister's testimony regarding the Veteran's hygiene is also contradicted by VA staff who have consistently noted the Veteran's appearance as acceptable. With respect to the date of the Veteran's retirement, as all the retirement dates offered fall before the rating period on appeal, it appears that the Board can determine the Veteran's entitlement to an increased rating and TDIU in spite of this inconsistency of record. Although it appears that the Veteran is suffering from serious PTSD symptoms, his clinical picture merits no more than a 70 percent rating. The Veteran has reported suicidal ideation on multiple occasions. The Veteran has a fixation on cleanliness that the July 2008 examiner felt qualified as obsessive. The lay testimony concerning the Veteran's excessive use of hand sanitizer and practice of washing multiple times a day corroborates that the Veteran suffers from obsessional rituals which interfere with routine activities. The Veteran appears to experience depression affecting his ability to function independently, appropriately, and effectively, as demonstrated by his initial inability to respond to the vocational evaluator because he was feeling "down." The Veteran's friend D.M. has testified that the Veteran experiences anxiety attacks when going into crowded places, and the Veteran has stated that he missed a scheduled VA examination in part because he could not cope with the stress of finding parking in the morning. This evidence indicates that he would be unable to adapt to more stressful circumstances. Taken together, these symptoms more closely resemble occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, which is indicative of a 70 percent rating. The Veteran does appear to be suffering from some symptoms that are typical of a 100 percent rating. For example, his tendency to sit in a room for days at a time could be demonstrative of gross impairment in thought processes or communication, as well as grossly inappropriate behavior. He has also described disorientation as to place. However, his clinical picture does not most closely resemble the total occupational and social impairment indicated by a 100 percent rating. Although the record indicates an isolated notation of the Veteran hearing voices, the record does not indicate that the Veteran is suffering from persistent delusions or hallucinations. The Veteran has reported experiencing suicidal ideation on multiple occasions, and has indicated a history of one suicide attempt, well before seeking treatment at VA. However, the most recent records relating to this issue are the April 2012 treatment note where he denies suicidal intent, and the March 2012 treatment note in which he asserts that he has had suicidal thoughts his entire life but denies plan or intent, stating that "he knows he has a purpose here." Therefore, it appears that the Veteran's current state of mind would be best described as experiencing suicidal ideation, but not presenting the persistent danger of hurting himself or others that is typical of a 100 percent rating. As discussed above, although the Veteran's sister has testified to the Veteran's neglect of hygiene, the Board considers the weight of the evidence of record to demonstrate that the Veteran is suffering from a fixation on cleanliness, which would indicate that he does not experience even intermittent inability to perform activities of daily living such as the maintenance of minimal personal hygiene. The record does not indicate that the Veteran's memory trouble has reached the point of being unable to recall the names of close relatives, his own occupation, or his own name. Moreover, the Veteran has been assigned GAF scores of 51 and 52, which are illustrative of moderate symptoms and moderate difficulty in social, occupational, or school functioning. Therefore, the Veteran's clinical picture does not most closely resemble one that is illustrative of a 100 percent rating. The Board recognizes that the symptoms listed in the rating criteria are not exclusive, but rather are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the symptoms experienced by the Veteran are not productive of functional impairment comparable to total occupational and social impairment needed for a 100 percent rating. He appears to have maintained a few friendships. One friend, S.S.., wrote that the Veteran has several acquaintances. The March 2012 VA treatment note indicates that the Veteran reported having three close friends that he wanted to "be there for." Although the Veteran does experience deficiencies in the area of social relationships, as indicated by his estrangement from his family and lack of communication with his neighbors, the evidence does not indicate that he is experiencing total social impairment. Therefore, a 100 percent rating is not warranted. TDIU A TDIU rating may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Consideration may be given to a veteran's level of education, special training, and previous work experience, but not to his or her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In Beaty v. Brown, 6 Vet. App. 532, 537 (1994), the Court of Appeals for Veterans Claims indicated that the Board cannot deny the veteran's claim for total rating based on individual unemployability without producing evidence, as distinguished by mere conjecture, that the veteran can perform work. Based on a thorough review of the record, the Board finds that the competent medical evidence supports the Veteran's claim for a TDIU. The Veteran is service-connected for PTSD, evaluated as 70 percent disabling, and hearing loss, evaluated as noncompensable. The combined evaluation is 70 percent, effective from March 2008. Thus, the Veteran satisfies the schedular criteria set forth at 38 C.F.R. § 4.16(a). The evidence demonstrates that the Veteran's service-connected disabilities render him unable to secure or follow a substantially gainful occupation, even though they do not warrant a 100 percent schedular evaluation. The January 2010 VA audio examination states that the Veteran's noncompensable hearing loss is not so severe as to prevent him from obtaining or maintaining gainful employment. The Veteran's private vocational evaluation does not discuss his hearing loss as a bar to employment. The Veteran has stated that his hearing loss requires him to turn his head to hear people, and that he does not hear everything that is said to him. However, he has not indicated that he feels that this difficulty in hearing significantly affects his employability, and so the Board will concentrate on his PTSD symptoms. The Request for Employment Information form reflects that the Veteran worked as a sales representative for a beer distributor from November 1995 until March 2007. The vocational report indicates that the Veteran has a high school education, and also took some college courses in time study. It appears that the Veteran excelled at his position as a sales representative, training other employees and winning awards for the best service department in the nation. In fact, it appears that he so excelled at training other employees that he found himself redundant, with nothing to do but sign off on the work performed by the employees he had trained. Although the Veteran discussed his temper making it difficult for him to train others and causing conflict with management and with potential customers, it does not appear that he was let go due to his PTSD symptoms or any related poor work performance. Rather, in the August 2012 hearing, the Veteran indicated that he was told that his position was being eliminated, but that he could reapply within the company for another one, although they could not guarantee that a position would be available. Instead, he decided to accept a buy out and retire. However, entitlement to a TDIU is not necessarily determined by the Veteran's reasons for leaving his previous employment. In this case, it appears that the Veteran's PTSD symptoms have worsened considerably since his retirement, resulting in his claiming and becoming service connected for PTSD. Although the January 2011 VA examiner indicated that the Veteran did not have total occupational and social impairment due to PTSD signs and symptoms, he did write that the Veteran's PTSD symptoms "impair occupational functioning via his inability to relate effectively with others, poor concentration, irritability, difficulty sleeping, and experiencing flashbacks and intrusive thoughts." The record reflects that his symptoms have caused the Veteran to become unreliable, as shown by his initial response that he could not participate in his vocational evaluation for a few days due to feeling "down", and his inability to attend a VA examination due to his fear of driving in the dark. His tendency towards isolation has grown to the point where he fears crowds, cannot cope with the noise and exuberance of a family Christmas party, and at times spends days sitting in a room and staring. He has also been described as moody and irritable, affecting his ability to relate to others. The record ultimately reflects that the Veteran's current PTSD symptoms create a functional impairment so severe as to deprive him of the basic level of reliability and efficient functioning required for any substantial and meaningful employment. There can be no doubt that further inquiry could be undertaken with a view towards development of the TDIU claim, but such would not materially assist the Board in this determination. Under the "benefit-of-the-doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52 (1993); see also Massey v. Brown, 7 Vet. App. 204 (1994). The Board finds that the Veteran has been unable to follow a substantially gainful occupation consistent with his educational and occupational experience, due to his service-connected disabilities, throughout the rating period on appeal. Accordingly, a TDIU is warranted. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1991). ORDER Entitlement to an initial rating in excess of 70 percent for PTSD is denied. Entitlement to a TDIU, throughout the rating period on appeal, is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs