Citation Nr: 1428337 Decision Date: 06/23/14 Archive Date: 07/03/14 DOCKET NO. 09-04 150 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), rated as 50 percent disabling prior to September 12, 2011, and 70 percent disabling from September 12, 2011 through June 4, 2013. 2. Entitlement to a total disability rating based upon individual unemployability (TDIU) for the period prior to June 5, 2013. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Fagan, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1967 to January 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which continued a 50 percent disability rating for PTSD. The Veteran was afforded a personal hearing at the RO in September 2009. A transcript of that hearing has been associated with the claims file. In February 2012, the Board denied entitlement to a rating in excess of 50 percent for PTSD. The Veteran appealed that denial to the Court of Appeals for Veterans Claims (Court). In a March 2013 Joint Motion for Remand, the parties moved to vacate the Board decision and remand the case to the Board. The Court granted the motion by an Order dated in March 2013. In July 2013, the Veteran's attorney submitted additional lay and clinical evidence in support of the Veteran's claims, accompanied by a waiver of RO consideration. See 38 C.F.R. § 20.1304 (2013). In August 2013, the Board remanded this matter to the Agency of Original Jurisdiction (AOJ) for additional development. In a January 2014 rating decision, the AOJ granted increased staged ratings for PTSD, assigning a 70 percent rating from September 12, 2011, and 100 percent from June 5, 2013. As the maximum schedular rating has been granted for the period from June 5, 2013, an increased rating to include a TDIU for that period is no longer on appeal. The issues have been amended on the cover page to reflect that fact. FINDINGS OF FACT 1. Prior to September 12, 2011, the Veteran's PTSD resulted in functional limitation most closely approximating occupational and social impairment with reduced reliability and productivity. 2. From September 12, 2011, the Veteran's PTSD has not been productive of total social and occupational impairment. 3. Throughout the period on appeal, the Veteran has been able to follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. For the period prior to September 12, 2011, the criteria for an evaluation in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 2. For the period from September 12, 2011, the criteria for a rating in excess of 70 percent have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 3. The requirements for establishing entitlement to a TDIU are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim 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). Here, regarding the increased rating claim, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in July 2007, prior to the initial RO decision in this matter, which addressed the notice elements. The letter informed the Veteran of what evidence was required to substantiate the increased rating claim, and of his and VA's respective duties for obtaining evidence. Additionally, regarding the TDIU claim, the AOJ provided the required notice letter in September 2013. As for the duty to assist, the AOJ has obtained and associated with the claims file the Veteran's service treatment records, post-service treatment records, and lay statements. The Veteran was also afforded multiple VA examinations relevant to his claim, including examinations in August 2007, September 2011, and December 2013, which the Board finds to be sufficient and adequate for rating purposes because the examiners described the Veteran's medical history, described his disability and associated symptoms in detail, and supported conclusions with analyses based on observations. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, VA's duty to assist has been satisfied. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Additionally, the Veteran was afforded a personal hearing before a Decision Review Officer (DRO) in September 2009. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the officer who chairs a hearing fully explain the issues and suggest the submission of evidence that may have been overlooked. Here, during the hearing, the DRO identified the issue and the Veteran testified as to his specific symptoms and why he believes a higher rating is warranted. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c) (2). As such, the Board finds that no further action pursuant to Bryant is necessary. Finally, the Board finds that its prior September 2013 remand instructions have been substantially complied with, in that the AOJ provided the Veteran the required notice letter, obtained outstanding VA treatment notes, provided the Veteran with a VA examination, and issued a supplemental statement of the case. See D'Aries v. Peake, 22 Vet. App. 97, 105. The Board finds that all necessary development has been accomplished, and appellate review does not therefore result in prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the AOJ has already assigned staged ratings. The Veteran contends that he is entitled to disability ratings greater than the currently-assigned 50 percent rating for the period prior to September 12, 2011, and the 70 percent rating assigned from September 12, 2011 through June 4, 2013, due to symptoms such as flashbacks, nightmares, anger, and depression. The Veteran's PTSD is rated under Diagnostic Code 9411, which is governed by a General Rating Formula for Mental Disorders. Under that Formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130 A higher 70 percent rating is warranted 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. 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. One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV)). A GAF score of 61 to 70 indicates some mild symptomatology (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, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect 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). Scores ranging from 31 to 40 reflect 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 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Prior to September 12, 2011 Based on a review of the evidence of record, the Board finds that an evaluation in excess of 50 percent is not warranted for the Veteran's PTSD for the period prior to September 12, 2011. In reaching this decision, the Board has reviewed the evidence of record, to include VA treatment and examination reports, Vet Center records, and the Veteran's statements, and considered all psychiatric symptomatology. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Vet Center treatment records dating from May 2006 to March 2007 show generally that the Veteran complained of stress relating to demanding family members, and reported symptoms of re-experiencing, anxiety, intrusive thoughts, vivid recall of combat experiences, and depression. Those records also show, however, that the Veteran went on vacation around August 2006, and, despite being in the same location with both his current wife and ex-wife, he "managed OK." In December 2006, it was noted that he "has good support" to get through Christmas, and, in February 2007, in discussing the demands of marriage and its impact on recovery, it was noted that despite tension with his wife, he "appears to be managing symptoms well." An August 2007 VA PTSD examination revealed reported symptoms of nightmares occurring once a week, daytime fatigue, sleep impairment, a short temper, anger while driving, passive suicidal ideation, and increased anxiety, amotivation, and anhedonia. He also reported a lack of intimacy in his marriage, and his wife's frustration with his tendency to isolate. He denied panic attacks, continued to work full time, and described "few problems with work." The Veteran's mood was dysphoric and his affect was restricted. Nevertheless, he was noted to be generally pleasant, cooperative, adequately groomed, and with good judgment and insight. His thought process was normal and there was no evidence of perceptual disturbances. The examiner assigned a GAF score of 53. VA treatment notes dating from October 2007 to August 2011 generally show that the Veteran attended group and individual therapy for his PTSD, and was prescribed medication for his symptoms of depression and sleep impairment. Those records document reported symptoms including outbursts of anger, road rage, episodes of verbal abuse, unexplained crying episodes, episodes of anxiety three or four times a week, difficulty with concentration at work, irritability, and disrupted sleep. They also show complaints of marital problems involving intimacy, communication, and alienation. Adjustments were made to the Veteran's medications at times, including in February 2008 and June 2009, and from February 2008, the Veteran's symptoms were described as severe. Assigned GAF scores ranged from 55 to 65. In September 2009, the Veteran had a hearing before a DRO. He stated that he had trouble sleeping. He indicated that he had part time work, and had difficulty doing the work. He stated that at his job people knew to let him work alone. He related that he and his wife did not get along, and that they slept in separate rooms. He stated that he had a short temper, bickered with his wife, and experienced road rage when driving. He indicated that his memory was worsening. The Veteran had another VA examination on September 12, 2011, upon which a 70 percent rating was based. He reiterated symptoms of dreams about Vietnam, problems with interpersonal relationships, irritability, and sleep impairment. He denied panic attacks, hallucinations, and suicidal thoughts. On mental status examination he appeared restless and tense, and his mood was dysphoric. However, speech was normal and he displayed a full range of affect. The examiner noted a persistent moderate level of PTSD that affected his family life, social life, and employment. A GAF score of 48 was assigned. Based on the evidence of record during the relevant period, the Board finds that, for the period prior to September 12, 2011, the Veteran's PTSD did not result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, to warrant a higher 70 percent rating. The Board acknowledges that the symptomatology reported by the Veteran at times could correspond with deficiencies in family relations, work and mood. However, the Board finds that the symptomatology does not more nearly approximate a rating in excess of 50 percent under the General Rating Formula as the symptomatology resulting in deficiency in family relations, work and mood are not of such a severity or frequency as to result in occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. In this regard, although there are some deficiencies in family relations and mood, such deficiencies are contemplated in the 50 percent rating criteria, which specifically considers disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Moreover, the record does not reflect difficulties in judgment or thinking as shown by the medical evidence. For instance, while difficulty in maintaining effective relationships is shown, an inability to do so is not. The Veteran was routinely found to have normal speech and thought processes. He has had constricted affect to a variable extent, and has had ongoing irritability, but he has not had near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. Indeed, in October 2007, regarding his mood, he stated, that it is "sometimes good, can't say I am always depressed or anxious." Moreover, he has generally denied suicidal ideation with limited exception, and has been shown to have good judgment. Although he has reported that he experiences road rage and has had verbal altercations, he stated in October 2007 that he was never violent, and the 2011 VA examiner also noted that the Veteran denied violence and had good impulse control. The GAF scores assigned during the period prior to September 12, 2011 do not reflect that the clinicians believed the Veteran was in danger of hurting himself or others, or had major impairment in several areas, as would be reflected by GAF scores below 41. Occupationally, while the Veteran reported some difficulty with concentration at work in June 2009, communication problems in July 2010, and interpersonal problems in general, the record shows that he continued to be productive and reliable at work throughout the relevant period. During his August 2007 VA examination the Veteran reported "few problems with the work," consistent with an earlier July 2006 report that he "has not had significant difficulties at work due to his symptoms" and "continues to function relatively well vocationally." In September 2010, the Veteran reported that work was stable. It is also noteworthy that the Veteran was often sent on travel for work, including in March 2010, April 2010, and April 2011, which demonstrates trust on the part of the employer, and a reliability on the part of the Veteran, as his employer entrusted the Veteran to represent the business on the road. He also appeared to be quite active or involved at work, despite suggestions of the Veteran and his supervisor that he was not doing his job or was otherwise unproductive or unreliable. In March 2008, the Veteran reported increasing demands at work, and in April 2008, he had to cut short his appointment because of time pressure due to a work appointment. In February 2009, it was noted he had to skip a weekly session due to a work commitment. In May 2009, he reported that he liked work, and in August 2010, another appointment was cut short because the Veteran was called to the workplace. Further, although the Veteran was laid off in November 2009, he was rehired by this same employer just months later when he went to "see if there might be work," as discussed in a February 2010 VA treatment. There is nothing in the record to suggest that the Veteran's layoff was related to PTSD, and the fact that the Veteran was rehired soon after suggests that he was considered competent to do his job. In this regard, it appears that it was a lack of available work, and not the Veteran's PTSD symptoms, that affected the Veteran's work. In January 2008, the Veteran reported that he continues to work and look for more work. Similarly, in February 2008, the Veteran reported that he was eager for more work and hopeful it will come. In June 2008, he was worried about having enough work. In April 2010, he reported that he "has more work which is good...," and in July 2010, there was increased work due to unusual heat. The Board also finds probative that when the Veteran was laid off in November 2009, and was encouraged to ask friends about possible work or to seek vocational rehabilitation counseling, his concerns about finding employment centered on his age; he did not express concerns over finding employment due to his PTSD symptoms. Socially, the Board again acknowledges that the Veteran experienced some social and marital problems. However, the record shows that a significant part of the marital discord related to the wife's health issues and her issues with the Veteran's daughters from another relationship, who had encountered legal problems and had problems with addiction and abuse. For instance, in June 2009, the Veteran was frustrated with his wife's unrelenting dislike of his children, and in April 2010, he stated that "My wife hates my kids...She told me to get out." In June 2010, he reported a rocky marriage and found his wife's attitude unacceptable, as she "hates" his daughters from another marriage who struggled with addiction. The Board also notes that despite the Veteran's feelings of isolation and alienation, in October 2007, the Veteran reported that he and his wife "actually have a connection and can get along well," and in March 2010, he reported that "there is still a connection" with his wife. Further, the Veteran reported a close relationship with his father and grandson, often expressed concern over and traveled to visit both his mother and father, and referenced friends in various appointments. In October 2007, he reported weekly contact with his parents and siblings and a close relationship with his daughters. In February 2008, he noted that he is close with his father. In March 2008, he discussed a trip to Vietnam "courtesy of a friend." In July 2008, he went to Nantucket for a week to "see old friends." In March 2009, he reported that he lost a friend to cancer and attended his funeral, noting that was "the seventh friend he has buried in two years." He also expressed trust in different individuals, including an aunt of his grandson in March 2009, and the father of his daughter's significant other in March 2011. Significantly, the record shows that the Veteran played an extremely active role in the lives of his daughters and grandson, and even took actions and went to court to gain some control over his grandson's life. The Veteran also appeared to be quite active during the relevant period. He was noted to golf throughout the record, including in October 2007, May 2009, and October 2009. In June 2010, he attended a Memorial Day event. He was also frequently noted to go to the gym, exercise, work in the yard, garden, and/or even attend AA meetings, including during VA treatment in October 2007, November 2007, March 2008, October 2009, February 2010, May 2010, and January 2011. The record also shows that the Veteran traveled quite a bit during the period on appeal. He went to California to visit his daughter in October 2007. In May 2008, he went to both Florida and Vietnam. He traveled to Nantucket for a week to "see old friends" in July 2008. Also in July 2008, he reported day trips with his wife, which were usually pleasant, and in August 2008, he reported that he "[j]ust had to get away with his wife." In December 2008, he referenced holiday plans, and in February 2009, the Veteran reported that he was leaving for Florida with his wife to "chill out." In August 2009, he planned to go to New York City to see a play. He also went to Florida to visit his parents in or around February 2009, October 2009, April 2010, and October 2010. In July 2010, he went to Cape Cod with his daughter and grandson, and in May 2011 he went to New York City with his daughters. Additionally, in spite of significant stressors, including problems related to his marriage; his wife battling cancer and possible alcoholism; problems facing his daughters, including incarceration, addiction, and domestic abuse; the suicide of a nephew; the care and/or death of his aging parents; and custody issues surrounding his grandson, the Veteran was consistently noted to have a GAF score of 55 or above until the September 12, 2011, VA examination. Indeed, during stressful times, he was often noted to be managing, have humor, display resiliency, and/or have a full range of affect. In December 2009, he was managing and had a positive outlook despite stressors such as being out of work and worrying about his daughter's relapse. In January 2010, it was noted that the Veteran had his car hit and dented on the way to the appointment but "was reasonably calm regarding this." In February 2011, the Veteran was noted to be quite distressed but also prided himself on being able to manage with minimal external supports. In March 2011, despite dealing with the arrest and incarceration of his daughter, and the arrest of his daughter's significant other with the Veteran's grandson in the car, the Veteran was assigned a GAF score of 65. In sum, upon consideration of the record as a whole, the Board finds that a rating higher than 50 percent is not warranted for the period prior to September 12, 2011. The record shows that while the Veteran experienced various symptoms, he was generally both reliable and productive during the relevant period in spite of those symptoms. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013) (although symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of occupational and social impairment). Despite numerous and serious stressors, the Veteran was able to cope, maintain gainful employment, maintain relationships with immediate family, extended family, and friends, and remain involved in travel and hobbies. The Veteran's disability picture prior to September 12, 2011, more closely approximates the criteria for a 50 percent rating than that of a 70 percent or higher rating. The Board has considered the lay assertions as to the severity of his condition, but finds the reports made to treating clinicians to be more probative than those made in conjunction with his claim for increase. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (2006) (conflicting statements of the veteran are factors that the Board can consider and weigh against a veteran's lay evidence); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). In sum, the Veteran's symptoms prior to September 12, 2011, were not so severe or frequent as to result in occupational and social impairment with deficiencies in most areas to warrant a higher 70 percent rating. Accordingly, a rating in excess of 50 percent for the period prior to September 12, 2011, is not warranted. From September 12, 2011 to June 4, 2013 In order to warrant a disability rating in excess of 70 percent for the period from September 12, 2011 through June 4, 2013, the evidence must show that the Veteran's PTSD is productive of total social and occupational 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; 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 Board acknowledges that the RO granted a 100 percent rating from June 5, 2013 based on the report of a VA social worker on that date, the July 2013 statement from a private vocational consultant and the December 2013 VA examiner determining that the Veteran's PTSD is productive of total social and occupational impairment. However, the Board is not required to extend that favorable determination to a time period prior to July 5, 2013, merely because the RO reviewed that evidence favorably. McBurney v. Shinseki, 23 Vet. App. 136, 139 (2009) ("[T]he Board, as the final trier of fact, is not constrained by favorable determinations below."). Rather, the Board finds that the evidence of record does not support that the effect of the Veteran's PTSD symptoms result in total social or occupational impairment during the period prior to June 5, 2013. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Initially, the record does not support a finding of total occupational impairment due to PTSD for the period in question. In this regard, the Veteran has been employed full time throughout this period. While the December 2013 VA examiner and a July 2013 private vocational consultant found that the Veteran was totally occupationally impaired and/or unemployable due to his PTSD, their conclusions appear to have been based on an inaccurate premise. For example, those opinions were based on assertions of the Veteran and his employer (who is notably also a longtime friend) that the Veteran works alone in the field most of the time and "does not tolerate other workers very well." However, the Veteran reported during July 2013 VA treatment, close in time to both of those assessments, that he "enjoys some of the blue collar workers he interfaces with at his job." That statement evidences not only an ability to tolerate and even enjoy interactions with others at work, but suggests some degree of ongoing interaction with others at his job. Moreover, despite the opinions in favor of total occupational impairment, and despite the supervisor's June 2013 statement that the Veteran is extremely unorganized and requires daily supervision to keep him focused, the Board observes that the Veteran has been sent on travel for work numerous times alone. Indeed, if the Veteran was as unreliable, disorganized, short tempered, unproductive, or incapable as suggested, the Board finds it unlikely that he would be sent on frequent travel for work as the sole representative of the business. See Madden v. Gober, 123 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the weight, credibility, and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence). Nor does the evidence support total social impairment. During the July 2013 private vocational assessment, the Veteran reported that he plays golf, periodically with "three close friends." Similarly, during January 2012 VA treatment, the Veteran reported that he was looking forward to an upcoming trip to Florida during which he planned to golf. Such evidence contradicts the June 2013 notation of the VA social worker that the Veteran has no friends and has no interest in any types of activities. The record also shows that he exercises, works in his garden, and in June 2012, he was in "good spirits" after attending his grandson's graduation from kindergarten. In fact, despite his reports of social isolation and the statements from his treating VA psychiatrist and social worker, the Veteran has maintained relationships with his wife, daughters, sister, parents, and even an ex-wife, and has a particularly close relationship with his grandson, whom he assumed responsibility for and had living with him for some time. Moreover, by admission of both the Veteran had his supervisor, he has maintained a friendship with his supervisor for over 30 years. The Board also finds probative the VA treatment notes throughout the appeal period, which consistently note the Veteran to be pleasant, cooperative, neatly dressed, and with adequate eye contact, and are otherwise silent for evidence of significantly impaired basic social functioning. In this regard, despite stressors related to his wife, his daughters (involving incarceration, custody issues, drugs, and domestic abuse), and his parents, the Veteran was routinely assigned GAF scores of 51, which are not indicative of total impairment. The Board acknowledges the June and July 2013 statements from the Veteran's treating VA social worker and psychiatrist that the Veteran's PTSD impairs or places "great strains" on his relationships, as well as the December 2013 VA examiner's opinion that the Veteran is totally socially impaired. However, the record shows that the Veteran has maintained relationships with his immediate and extended family, has played an extremely active role in the lives of his daughters and his grandson, has maintained friendships, and participates in activities such as golf. Thus, to the extent the reports upon which the 100 percent rating were based are argued to reflect the status of his disability prior to June 5, 2013, the Board finds the most probative evidence does not reflect total social impairment. Thus, as the preponderance of the probative evidence does not reflect symptomatology that more nearly approximates PTSD productive of total social and occupational impairment during the period from September 12, 2011 through June 4, 2013, a rating in excess of 70 percent for this period is not warranted. The Board has again considered the lay assertions as to the severity of his condition during the period in question, but finds the reports made to treating clinicians to be more probative than those made in conjunction with his claim for increase. See Buchanan and Cartright, both supra. Other Considerations The Board has also considered whether referral for extraschedular consideration is warranted for any period on appeal. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the rating criteria contemplate the Veteran's disability from his service-connected PTSD. As noted above, the Board has considered all symptomatology related to his PTSD, not just the symptomatology listed in the rating criteria, and focused on the impact of his symptoms on occupational and social impairment. See Mauerhan, 16 Vet. App. 436. For the reasons stated above, the Board has concluded that the Veteran's level of such occupational and social impairment is adequately reflected by the current schedular ratings assigned. As such, the Board finds that the manifestations of the Veteran's PTSD are contemplated in the rating criteria. There is no indication of any exceptional or unusual disability picture. The rating criteria are therefore adequate to evaluate the Veteran's service-connected PTSD and referral for consideration of extraschedular rating is not warranted. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. III. TDIU The Board notes the Veteran's attorney first raised the claim for TDIU as due to PTSD in July 2013 immediately following remand of the case from the Court. The Veteran essentially contends that he is entitled to a TDIU for the period prior to June 5, 2013 because he works in a protected environment and his employment is marginal. He asserts that he is currently employed only because his employer is a friend who is aware of and accommodates his PTSD. His employer has also submitted a June 2013 statement in support of the Veteran's claim, noting that he would not have kept the Veteran on if he were not a friend. A total rating for compensation purposes 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 service-connected 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 C.F.R. § 4.16(a). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, in the case of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet these schedular percentage standards, the case should be submitted to the Director, Compensation and Pension Service, for extra-schedular consideration. See 38 C.F.R. § 4.16(b). For a veteran to prevail on a claim for a TDIU, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether a veteran is capable of performing the physical and mental acts required by employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). In determining whether an appellant is entitled to a total disability rating based upon individual unemployability, neither appellant's nonservice-connected disabilities nor advancing age may be considered. 38 C.F.R. § 4.19. Following a careful review of the record, the Board finds that the Veteran's current employment is not marginal and that he has been engaged in substantially gainful employment during the period on appeal. The record shows that the Veteran has worked as a boilermaker with Condenser and Heat Exchanger Services, either full-time or almost full-time with between 35 to 40 hours per week, since 1982. Recent VA treatment records dated in November 2013 confirm that the Veteran is still working. Thus, the evidence shows that the Veteran has been employed throughout the pendency of his increased rating claim. The record also shows that the Veteran's employment has been more than marginal. In October 2013, the Veteran and his employer submitted statements indicating that the Veteran earned approximately $48,126 during the prior 12-month period. While the Veteran reported on his statement that he earned $37,000 during the past 12-months, the Veteran's employer certified $48,126, and the Board accords more value to the employer's certification. That amount far exceeds the poverty threshold for an individual, which was less than $15,000 in and prior to 2013, according to the U.S. Department of Commerce, Bureau of the Census. As the Veteran's earned annual income exceeds the poverty threshold, his employment cannot be considered marginal on that basis. Nor does the Board find that the Veteran's employment is marginal on the basis that it is in a protected environment. First, the Veteran's employer is not his family's business. Indeed, the Veteran has reported his employer to be a longtime friend. Second, the Board finds that the extent to which the Veteran's PTSD symptoms are reported to interfere with his work and require a sheltered or protected work environment are not consistent with reports by the Veteran to treating clinicians and are not persuasive. See Madden v. Gober, 123 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the weight, credibility, and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence). For instance, while the Veteran and his employer have reported in support of the instant claim that the Veteran's PTSD symptoms are so severe that he works in isolation, the Board notes that during July 2013 VA treatment, the Veteran reported that he enjoyed "some of the blue collar workers he interfaces with at his job." Such evidence supports that the Veteran not only has interaction with others at work, but that such interactions are enjoyable. Additionally, a July 2006 VA examination report notes that the Veteran "has not had significant difficulties at work due to his symptoms" and "continues to function relatively well vocationally." Similarly, during an August 2007 VA examination, the Veteran himself reported that he continued to work full time as a boilermaker and had "few problems with the work." In February 2008, he was eager for more work and in April 2009 he reported enjoying his time working away from home. In May 2009, he reported that "[h]e likes work but feels that he is not making enough money." He again reported enjoying work out of town in March 2010, and in April 2010, he reported having more work "which is good." In September 2010 work was reported as stable. Such evidence does not support that the Veteran's PTSD symptoms have interfered with work to the degree reported by the Veteran and his employer. Indeed, the employer's report of "several verbal altercations with others over the years" (emphasis added), when the Veteran has worked there for over 30 years, hardly supports that the Veteran is unemployable. While the Veteran expressed frustration with a "work situation" in September 2013, he did not elaborate on the nature of the situation, nor did he otherwise indicate that it had anything to do with his PTSD. Nor did he indicate that any other general problems or frustrations with work reported elsewhere in the record were due to his PTSD, though he did report being bored and tired of working. In any event, this is after he was assigned a 100 percent schedular evaluation. The Board does acknowledge the Veteran's reports that he had problems with concentration in June 2009; that only the fact that his employer knows him makes his work possible in September 2009; that he is grateful to his employer for keeping him on even though he is not really doing his job in June 2010; and, problems with communication in July 2010. However, the Board finds that the totality of the credible and probative evidence does not support that the Veteran's PTSD symptoms render him unemployable such that his employment can be considered marginal. Indeed, seven years of ongoing treatment records show limited reports of problems with work due to PTSD symptoms, and essentially no reports of conflicts with others at work or being counseled or reprimanded by his employer due to his behavior. Notably, during VA treatment, while the Veteran reported hostile verbal exchanges with his wife in December 2007, a hostile verbal exchange with his wife and a man at the airport in January 2008, and with his grandson's father in February 2009, the Veteran did not report any confrontations or hostile exchanges with any individuals at work. Further, despite the Veteran's assertions relating to the severity of his symptoms, it appears that he and his employer/friend have successfully maintained their friendship and professional relationship for over 30 years, so much so that his employer took the Veteran on a trip to Vietnam with him. The Board also finds probative the fact that the Veteran was entrusted to travel alone in support of the business. That evidence contradicts the employer's June 2013 statement the Veteran requires daily or constant supervision. Moreover, as discussed above, the Veteran was rehired by his employer in February 2010 following a layoff, and also called in to the workplace when the power went out in August 2010, suggesting that the Veteran was valued and/or relied upon at work. , Finally, for reasons discussed above, the Board finds the July 2013 private employability evaluation to be unsupported by the evidence of record, which shows that the Veteran has been gainfully employed throughout the period on appeal, and has been reliable and productive at work. Indeed, the Veteran's assigned GAF scores throughout the entire period on appeal, with the exception of one assigned in September 2011, have ranged from 51 to 65, and suggest moderate difficulty in social and occupational functioning. They do not support a finding that the Veteran is so occupationally impaired as to be unemployable. Indeed, while the July 2013 vocational consultant opined the Veteran has been unemployable since 2005 based on her opinion that his occupation was "sheltered", her detailed discussion did not address the Veteran's reports to clinicians that he "has not had significant difficulties at work due to his symptoms" and "continues to function relatively well vocationally" (July 2006), that he had "few problems with the work" (August 2007 VA examination), and that work was stable (September 2010). Moreover, she did not address that the Veteran was often sent on travel for work, including in March 2010, April 2010, and April 2011, which suggests that the employer trusted him to appropriately represent the business on the road, that the Veteran appeared active at work in March 2008, April 2008, February 2009 and August 2010 when he reported increasing demands at work/and or having to miss appointments or leave early due to work. Nor did the Vocational Counsel note the Veteran's report in May 2009 that he liked work, or that he was called during an emergency power outage. As the vocational counselor's opinion did not contemplate these relevant facts, the Board finds the opinion warrants little probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion) The ultimate determination of whether a veteran is capable of substantial gainful employment rests with the VA adjudicator, not a medical examiner. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed.Cir.2013) (citing 38 U.S.C. § 5103A(d)(1)) (the VA adjudicator has the ultimate responsibility for a TDIU determination and VA is not required in every case to obtain a single medical opinion regarding the combined impact of all service-connected disabilities). Here, while an attempt has been made to portray this Veteran's full time employment, which results in income of $48,000 a year, as sheltered and protected, the information provided by the Veteran to VA clinicians reflects that the Veteran was a capable employee who was pleased to have work, was able to travel for work alone, and was engaged in his work, to the point where he cancelled or cut short appointments due to work activities. The Board finds it unlikely that his employer, whether a friend or not, would pay the Veteran a salary of $48,000 a year, rehire him after a layoff, allow him to travel for business alone, and call him in to work for an emergency, if the Veteran was not capably performing activities consistent with his employment. "Substantially gainful employment" means "the ability to earn 'a living wage.'" Bowling v. Principi, 15 Vet. App. 1, 7 (2001). The Veteran is clearly accomplishing that here. See Van Hoose, 4 Vet. App. 361 (the question is whether the veteran is capable of performing the physical and mental acts required by employment). In summary, the Board finds that the preponderance of the competent, credible, and persuasive evidence is against a finding that the Veteran's full time employment constitutes marginal employment. As such, the Board concludes that the Veteran's employment during the period in question constitutes substantially gainful employment, and entitlement to a TDIU for the period prior to June 5, 2013 is denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to a disability rating in excess of 50 percent for PTSD for the period prior to September 12, 2011, is denied. Entitlement to a disability rating in excess of 70 percent for PTSD for the period from September 12, 2011, is denied. Entitlement to a TDIU is denied. ______________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs