Citation Nr: 1428583 Decision Date: 06/24/14 Archive Date: 07/03/14 DOCKET NO. 08-39 358 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A.M. Ivory, Counsel INTRODUCTION The Veteran served on active duty from October 1967 to May 1969. This matter comes before the Board of Veterans' Appeals (Board) from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In February 2008 the RO rating decision granted the Veteran service connection and assigned an initial 30 percent disability rating effective September 26, 2006. An April 2011 rating decision granted the Veteran a higher initial rating of 50 percent effective September 26, 2006. Inasmuch as a rating higher than 50 percent for the service-connected PTSD is available, and inasmuch as a claimant is presumed to be seeking the maximum available benefit for a given disability, the claim for a higher rating, as reflected on the title page, remains viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran testified before the undersigned in August 2011. A transcript of the hearing is of record. This appeal was previously remanded by the Board in September 2011 and in September 2013 for additional development. As the requested development has been completed, no further action to ensure compliance with the remand directive is required. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Board notes that in August 2006 the Veteran appointed the Virginia Department of Veterans Services as his representative; however, during the pendency of the appeal, in August 2011 the Veteran revoked power of attorney and submitted a new VA 21-22 appointing Veterans of Foreign Wars as his representative. This appeal was processed using the Veterans Benefit Management System (VBMS) paperless, electronic claims processing system. In addition to the VBMS file, there is also an electronic (Virtual VA) paperless claims file. The Virtual VA claims file includes VA treatment records that were reviewed by the RO in the May 2013 supplemental statement of the case (SSOC) and by the Board. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity as a result of sleep impairment, depression, and some impaired impulse control, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 2. The Veteran is not precluded from securing or following substantially gainful employment as a result of his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for a TDIU are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.340, 3.341, 4.16, 4.19 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. The Board observes that the Veteran has appealed with respect to the propriety of the initially assigned rating for his PTSD from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for service connection for PTSD was granted and an initial rating was assigned in the February 2008 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records and post-service VA and private treatment records have been obtained and considered. The Veteran was afforded a VA examination in May 2010 and October 2013. Neither the Veteran nor his representative has alleged that such is inadequate for rating purposes. Moreover, the Board finds that the examinations, specifically the October 2013 VA examination, is adequate in order to evaluate the Veteran's service-connected PTSD as it included an interview with the Veteran, a review of the record, and a full mental status examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination report of record is adequate to adjudicate the Veteran's initial rating claim and no further examination is necessary. In September 2011 the Board remanded the Veteran's claim in order to obtain VA treatment records and records from the Social Security Administration (SSA). The Veteran's VA treatment records and SSA records have been obtained and associated with the Veteran's claims file. In September 2013 the Board remanded in order to obtain VA treatment records, obtain private treatment records, to provide the Veteran the appropriate VCAA notice for TDIU rating, to send to the Veteran VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, to afford the Veteran a VA examination, and to readjudicate the Veteran's claim. The Board notes that the additional treatment records that were obtained contained the Veteran's October 2013 VA examination, and the VA treatment records associated with the Veteran's claims file are as recent as April 1, 2013. In October 2013 the RO sent the Veteran a VCAA notice for TDIU rating, the information to obtain outstanding private treatment records, VA Form 21-4142 Authorization and Consent to Release Information to the Department of Veterans Affairs, and VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. In October 2013 the Veteran sent a signed VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs; however, the only doctors listed were VA doctors. As noted above the Veteran's VA treatment records are already associated with his claims file; thus, there is no evidence of any outstanding treatment records. The Veteran did not return VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. Information that would have been contained therein pertinent to the claim therefore cannot be considered. The duty to assist in the development and adjudication of a claim is not a one-way street. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). VA is under no further obligation to develop the claim in this regard. Wood v. Derwinski, 1 Vet. App. 190, 193, reconsideration denied, 1 Vet. App. 406 (1991) (per curiam). As noted above, the Veteran was afforded a VA examination in October 2013. The Veteran's claims were then readjudicated by the RO in the November 2013 SSOC. As the requested development has been completed, no further action to ensure compliance with the remand directive is required. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Board notes that in November 2013 the Veteran returned an SSOC Notice Response stating that he had more information or evidence to submit in support of his appeal and that VA will wait the full 30 day period to give him a chance to submit the information but he understood that if the evidence was not submitted within the 30 day period his case will be returned to the Board. The Board notes that as the date of this decision, which is substantially after the 30 day period that expired in December 2013, the Veteran has not submitted any additional evidence and thus, the Board may proceed with the adjudication of the Veteran's claims. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996); Wood v. Derwinski, 1 Vet. App. 190, 193, reconsideration denied, 1 Vet. App. 406 (1991) (per curiam). Additionally, in September 2011, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned Veterans law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the DRO or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in September 2011. At the hearing the Veterans Law Judge noted the issue on appeal. Also, information was solicited regarding the Veteran's PTSD symptomatology. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, as the Veteran identified additional evidence at the hearing and such testimony gave rise to the need for medical inquiry into the nature and severity of his PTSD, the Board remanded this case in September 2011 and September 2013 so as to obtain all outstanding records as well as medical opinions regarding the severity of the Veteran's PTSD. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claim decided herein. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim decided herein based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims on appeal. II. Analysis PTSD A February 2008 rating decision granted the Veteran service connection for PTSD and assigned an initial rating of 30 percent effective September 26, 2006. During the pendency of the appeal, an April 2011 rating decision granted the Veteran a higher initial rating of 50 percent effective September 26, 2006. He contends that such disability is more severe than as reflected by the currently assigned rating. Therefore, the Veteran claims that he is entitled to a higher initial rating for his PTSD. However, the Board finds that the preponderance of the evidence is against the Veteran's claim of a rating in excess of 50 percent. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's PTSD is currently evaluated under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411. Under such regulations, ratings are assigned according to the manifestation of particular symptoms. 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 American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). A 30 percent rating is warranted for 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). Id. 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. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Id. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the DSM-IV, GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness". There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown , 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The Veteran's claims file includes treatment records from the Vet Center from March 2006 and September 2006. In March 2006 he looked unkempt, had a suspicious/defensive manner, had above average intelligence, his speech was rapid/pressured, his memory function was impaired, his motor activity was tense, and he was oriented to place and person. It was noted that he had not seen a doctor in years. In September 2006 it was stated that he had occupational difficulties because he was on medical leave due to very high blood pressure/anxiety at work. He was noted to be divorced, lived alone, and socially isolated. His symptoms were described as serious and he had significant impairment in occupational and social functioning. In March 2008 the Veteran's private physician wrote a letter and stated that the Veteran's PTSD was significantly affecting his life. It was noted that he had difficulty with sleep, regular nightmares, and flashbacks. His erratic sleep patterns made work more problematic. He had an avoidance of stimuli associated with the trauma and numbing. He presented with stumbling speech, poor eye contact, and related that he goes through a "lot of changes" in one day. His affect was depressed and his speech was slow and hesitant. He had difficulty working with others and felt that he was always angry and "goes off" at the slightest provocation. He had persistent symptoms of increased arousal. He had difficulty with his sleep and as a result was unable to work full time; he was unable to stay asleep over 3 hours straight and this impacted his overall ability to function. He tended to stay to himself and was detached from others. He tried to increase his hours on the job but then the depressive component became exacerbated and he was unable to fulfill the job requirements. His memory and concentration declined. Under stress his symptoms became exacerbated. He reported difficulty with his anger, anxiety, and felt that he was irritable most of the time. He felt that the only way he survived on the job was working at night when there was little to no one around. It was stated that the Veteran's PTSD was affecting all areas of his functioning and it significantly impacted his personal relationships. In addition, it decreased his ability to work. At the Veteran's May 2010 VA examination it was noted that he was in a five-year relationship, had custody of his son, and continued to occasionally interact with several long-term friends. He reported no changes in his leisure activities; he watched television at home and occasionally went to parks alone. He did not have a history of suicide attempts or violence. On examination his speech and psychomotor activity were unremarkable; he was cooperative and attentive toward the VA examiner. His affect was normal and his mood was good. He was oriented to person, time, and place. His thought process and thought content were unremarkable. He had no delusions and he understood the outcome of his behavior. His intelligence was average. He had sleep impairment and took medication to address his sleep issues and his nightmares. It was noted that he had angry outbursts as exemplified by his road rage and cursing people out in stores. He had obsessive/ritualistic behavior that was manifested by looking out the windows to check his environment. He did not have panic attacks, suicidal thoughts, or homicidal thoughts. He was able to maintain minimum personal hygiene and had no problems with activities of daily living. His remote memory was normal but his recent and immediate memory were mildly impaired; he had to write things down in order to remember them. He made efforts to avoid thoughts, feelings, or conversations associated with his military trauma. He had feelings of detachment and foreshortened future. The VA examiner stated that the prognosis for improvement was favorable if the Veteran continued with medication and committed to participate in evidence-based treatment. The Veteran was afforded a VA examination in October 2013 and he reported not going to therapy. He endorsed chronic mood disturbance described as mixed depression and anxiety. He also reported hypervigilance, regular thoughts and memories distressing to him about Vietnam, and problems with concentration and subjective memory difficulty. He also had emotional detachment, a sense of doom, and general avoidance in talking about his military experiences. He described his nightmares as fairly vivid and distressing to him but he did not have a clear recollection of them when he woke up; his girlfriend reported that he hit her on the back when he slept, she denied any serious injuries by him. He experienced a startle response when he heard planes or helicopters. He reported irritability but no episodes of physical aggression. He had a constellation of symptoms that adversely impacted his mood, sleep, concentration and subjective short-term memory, and mildly impacted his interpersonal functioning. He had good relationships with his long term girlfriend, his son, and friends; though he endorsed some emotional detachment and mild numbing. He was able to form relationships and maintain them. The VA examiner opined that it was less likely as not that the Veteran's PTSD rendered him unable to secure or follow a substantially gainful occupation. He retired in 2006 and denied obtaining any additional employment (including part-time) since the last examination. It was noted that he worked for over 20 years at a hospital and demonstrated steady and gainful employment; additionally, the VA examiner stated that it was noted in other medical records that he retired due to hypertension. The VA examiner stated that the Veteran's PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. The Veteran's PTSD symptomatology was manifested by depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), flattened affect, and disturbances of motivation and mood. On examination he was alert, fully oriented across all spheres, cooperative, demonstrated very good grooming and hygiene, and made appropriate eye contact; also, he was well-dressed. His speech was clear and coherent; his rate, rhythm, and volume were within normal limits. He denied any current suicidal or homicidal ideation, intent, or plan. He had no current hallucinations or delusions, hypo/manic episodes, panic attacks, or true flashbacks. The VA examiner stated that a brief mental health status measure suggested that he was endorsing difficulty with concentration, delayed recall of information, and short-term memory; however, no gross cognitive impairment was reported nor observed. He denied any episodes of disorientation, wandering, and reported that he had an active driver's license and drove to the appointment alone. He reported full and independent management of his activities of daily living. Also of record are the Veteran's SSA records; which included a June 2007 opinion and an April 2009 opinion. In June 2007 it was stated that he may require additional supervision and because of anger outbursts he worked better in a solitary work environment. In April 2009 a private physician stated that the Veteran's PTSD affected all areas of functioning and decreased his ability to work. In addition to the above medical evidence there are also VA treatment notes that show the same symptomatology as described above. The exception is that a January 2008 VA treatment note stated that the Veteran affirmed irritability and anger outbursts that resulted in violence. Included in the Veteran's VA treatment records are VA treatment notes from March 2011 to May 2011 that repeatedly stated that the Veteran was appropriately groomed, denied psychosis and suicidal ideation, and was psychologically stable. In February 2013 it was indicated that the Veteran was psychiatrically stable and that he did not feel down, depressed, or hopeless. He also did not have little interest or pleasure in doing things; he was not suicidal. Also in February 2013 it was noted that he was unable to sleep and had nightmares. He stopped taking his medication because it made him feel weird. Again, the Board notes that the symptoms noted in the rating criteria are not intended to be an exhaustive list, but are examples of the types and severity of symptoms that indicate a certain level of disability. The United States Court of Appeals for the Federal Circuit has acknowledged the "symptom-driven nature" of the General Rating Formula and that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed. Cir. 2013) ("[The veteran]'s proposed interpretation, meanwhile, would nullify this clear structure by reading relevant symptomatology almost entirely out of the regulation at the 70 percent level. Under his construction, a veteran whose symptoms correspond exactly to a 30 percent disability could attain a 70 percent rating simply by demonstrating that those symptoms have adversely impacted his work, school, family relations, judgment, thinking, and mood. This interpretation runs contrary to the regulation's plain language."). The Board has determined that based on the overall evidence of record the effects of the symptoms of the Veteran's PTSD have not been described to be of a type, frequency and severity that rise to the level of a 70 percent schedular rating. Based on the evidence of record, the Board finds that, for the entire appeal period, such disability is manifested by occupational and social impairment with reduced reliability and productivity and it is does not result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to symptoms of the frequency, duration, and severity as contemplated in a 70 percent rating. While the Vet Center stated in September 2006 that the Veteran had significant impairment, his private physician stated in March 2008 that his PTSD significantly affected his life including his functioning and his personal relationships, and in April 2009 a private physician stated that his PTSD affected all areas of functioning and decreased his ability to work, the Board finds that the Veteran's overall disability picture is not manifested by severe symptomatology. At the May 2010 VA examination, the Veteran reported that he retired due to his nonservice connected hypertension. He stated that his job kept him busy so that he was able to avoid dealing with his PTSD symptoms. At the hearing, the Veteran testified that he was told that he was going to have a stroke if he did not retire due to his very high blood pressure. (See Transcript page 19). The currently assigned high rating of 50 percent is recognition that the Veteran is experiencing an increase in his PTSD symptoms due to his retirement. Significantly, the record shows that the impact of the Veteran's symptoms on his occupational functioning was not the severity as contemplated in a 70 percent rating. Moreover, it was specifically noted at the October 2013 VA examination that the Veteran's PTSD resulted in the 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); the Board notes that this is the criteria for a 30 percent disability rating. The Veteran's symptomatology does not manifest to a 70 percent disability rating. While the Veteran reported that he had suicidal thoughts in the December 2008 VA Form 9, and at the Board hearing he testified that he entertained such suicidal thoughts when driving across bridges, he nevertheless indicated that he had no past attempts at suicide and he recognized that it would be "crazy" to do so. (See Transcript pages 26-27). Also, the Veteran reported in May 2010, March 2011, May 2011, October 2013, and February 2013 that he did not have suicidal ideations. Thus, the Veteran does not demonstrate suicidal ideations of the frequency, duration, and severity as contemplated in a 70 percent rating. While he reported in May 2010 that he had obsessive/ritualistic behavior that was manifested by looking out the windows to check his environment it was also noted that he had no problems with activities of daily living. Additionally, though it was noted in October 2013 that he had hypervigilance there is no evidence that at any point during the pendency of the appeal his obsessive/ritualistic behavior and hypervigilance manifested to the point where it interfered with routine activities to any significant degree. Thus, the Veteran's symptoms do not impact his functioning to the degree of frequency, duration, and severity contemplated in a 70 percent rating. In March 2008 the Veteran's speech was noted to be stumbling; however, on examination in May 2010, April 2011, and October 2013 his speech was noted to be normal. Thus, the Board finds that overall the Veteran's speech is not found to be illogical, obscure, or irrelevant. In September 2006 it was noted that the Veteran was socially isolated. In March 2008 his affect was depressed and it was noted that his depression became exacerbated when he tried to increase his hours at work. At the May 2010 VA examination his affect was normal and he had no problems with activities of daily living. In October 2013 he endorsed mixed depression and anxiety but he reported that he had full and independent management of his daily activities. In February 2013 he stated that he did not feel down, depressed, or hopeless. Thus, there is no credible evidence of near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. The Board notes that the Veteran does have some symptomatology of impaired impulse control; in March 2008 he reported that he was always angry and "goes off" at the slightest provocation and in May 2010 he stated that he had angry outbursts as exemplified by his road rage and cursing people out in stores. There is one notation, January 2008, that the Veteran reported that his irritability and anger outbursts resulted in violence; however, that is the only notation of violence and in May 2010 it was specifically stated that he did not have a history of violence. Moreover, in October 2013 the Veteran reported irritability but that he had no episodes of physical violence. Thus, there is no credible evidence that the Veteran's outbursts are of the frequency, duration, and severity akin to impaired impulse control with periods of violence contemplated by a 70 percent rating. At the October 2013 VA examination it was specifically noted that he did not have spatial disorientation. While the Vet Center treatment report stated that the Veteran was unkempt it was noted at both the May 2010 and October 2013 VA examinations that he was able to maintain good personal hygiene. VA treatment records showed the Veteran regularly appeared at appointments with good hygiene. Thus, the Veteran's rare occasion of neglect of good hygiene is not of the frequency, duration, and severity contemplated in a 70 percent rating. In June 2007 it was stated that because of anger outbursts he worked better in a solitary work environment and at the March 2008 VA examination it was noted that he was unable to adapt to work because of the stress but he could work at night when no one was around. However, in October 2013 it was noted that he worked for over 20 years and demonstrated that he could work and retired due to hypertension. Difficulty in establishing and maintaining effective work relationships is contemplated in the currently assigned rating. The Veteran successfully adapted to a work setting. In addition, though it was stated in September 2006 that the Veteran was isolated socially and in March 2008 his PTSD significantly impacted his personal relationships, he reported in May 2010 that he was in a five year relationship, had custody of his son, and occasionally interacted with several long term friends. In October 2013 it was stated that his interpersonal functioning was mildly impacted and that though he had some emotional detachment and mild numbing, he was able to form relationships with his girlfriend, son, and friends, and he was able to maintain them. Thus, there is no credible evidence that he has an inability to establish and maintain effective relationships. The Board notes that in addition to the listed symptomatology the Veteran's PTSD is manifested by sleep impairment and memory impairment. At the October 2013 VA examination it was noted that his symptoms adversely impacted his mood, sleep, concentration, and subjective short term memory but it only mildly impacted his interpersonal functioning. Additionally, the Board notes that the Veteran was assigned a GAF score of 52 in January 2008, a GAF score of 40 in March 2008, a GAF score of 62 in May 2010, and a GAF score of 55 in October 2013. A GAF score between 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores of 61 to 70 are indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. 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). While a GAF score of 40 represents some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood, the Board finds that the evidence underlying the GAF score is similar to the evidence underlying the subsequently assigned GAF scores. There is no clear demarcation line showing that the overall severity, duration, and frequency of the Veteran's symptoms were worse in the earlier period such that a higher rating would be appropriate. Therefore, as the Veteran's PTSD symptoms, as detailed previously, are contemplated by his 50 percent evaluation and, absent more severe symptoms, a higher rating is not warranted. The Board finds that, since the date of claim, the Veteran's PTSD symptomatology, described above, does not more nearly approximate a 70 or 100 percent rating. The Board finds that the evidence fails to demonstrate primarily symptomatology of gross impairment in thought processes or communication; delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living; disorientation to time or place; or memory loss for names of closes relatives, own occupation, or own name. The Board notes that while there are notations of memory loss it has never been described as memory loss for names of close relatives, own occupation, or own name. Therefore, for the foregoing reasons, the Board finds that the Veteran is not entitled to a rating in excess of 50 percent for PTSD. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that his symptomatology has been consistent throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b) (1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. The Board finds that the Veteran's PTSD symptomatology is fully addressed by the rating criteria under which such disability is rated. In this regard, all of the Veteran's psychiatric symptomatology is contemplated by the rating criteria. There are no additional symptoms of his PTSD that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). TDIU In order to establish entitlement to TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The criteria provide for a TDIU when, due to service-connected disability, a Veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. For the purposes of this analysis, disabilities affecting a single body system, such as the cardiovascular-renal system, will be considered a single disability. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the Veteran does not meet the percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). In this case, the Veteran is service-connected for PTSD (rated as 50 percent disabling effective September 26, 2006) and a residual gunshot wound of the left hand (rated as noncompensable effective November 20, 1973). The Veteran's combined evaluation is 50 percent disabling from September 26, 2006. As such, the Veteran does not meet the minimum scheduler criteria for TDIU under 38 C.F.R. § 4.16(a). However, even when the percentage requirements are not met, entitlement to a total rating, on an extra-schedular basis, may nonetheless be granted, in exceptional cases, when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. §§ 3.321(b), 4.16(b). A review of the Veteran's claims file indicates that he has his GED and retired in 2006 from St. Mary's Hospital after over 20 years of employment. After a careful review of the Veteran's claims file, the Board finds that the Veteran is not entitled to a referral for consideration of assignment of a TDIU rating on an extra-schedular basis. The medical evidence herein above describes the effect the Veteran's PTSD symptomatology has on his employment in detail; however, the Board herein below reiterates the pertinent medical evidence. In September 2006 his symptoms were described as serious and that he had significant impairment in occupational and social functioning. It was also stated that he was on medical leave due to very high blood pressure/anxiety at work. In June 2007 it was stated that he may require additional supervision and because of anger outbursts he worked better in a solitary work environment. In March 2008 the Veteran's private physician opined that his PTSD decreased his ability to work. He had difficulty with his sleep and as a result was unable to work full time; he was unable to stay asleep over 3 hours straight and this impacted his overall ability to function. He tended to stay to himself and was detached from others. He tried to increase his hours on the job but then the depressive component became exacerbated and he was unable to fulfill the job requirements. In April 2009 a private physician stated that the Veteran's PTSD affected all areas of functioning and decreased his ability to work. In May 2010 it was noted that he retired from his job of more than twenty years due to problems with hypertension. In addition, it was noted that he worked alone and on the night shift for the duration of his employment. The October 2013 VA examiner opined that it was less likely as not that the Veteran's PTSD rendered him unable to secure or follow a substantially gainful occupation. He retired in 2006 and denied obtaining any additional employment (including part-time) since the last examination. Crucially, it was noted that he worked for over 20 years at a hospital and demonstrated steady and gainful employment; additionally, the VA examiner stated that it was noted in other medical records that he retired due to hypertension. While the above medical evidence describes his limitations on employment as a result of his PTSD the Board finds that the relevant inquiry is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, either singularly or jointly, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. Though there are multiple statements regarding the limitations of his PTSD on his employment, i.e. the need for extra supervision or that he had to work alone or on night shift, there is actually only one medical opinion of record that specifically addresses the question of whether the Veteran's PTSD renders him unemployable. This opinion, the October 2013 VA medical examination opinion, stated that it was less likely as not that the Veteran's PTSD rendered him unable to secure or follow a substantially gainful occupation. The VA examiner also stated that the Veteran worked for over 20 years at a hospital and demonstrated steady and gainful employment; moreover, the VA examiner stated that it was noted in other medical records that he retired due to hypertension. The Board finds that the October 2013 VA examiner offered clear conclusions with supporting data as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Consequently, the Board assigns great probative value to the VA examiner's opinion. Thus, the Board finds that the Veteran's service-connected PTSD does not render him unemployable. The sole fact that a Veteran is unemployed or has difficulty finding employment is not enough to award TDIU, since a high compensation rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. In this regard, the Board notes that the Veteran has been awarded a 50 percent rating in light of the social and occupational impairment caused by his PTSD. The question is whether the claimant is capable of performing the physical and mental acts required for employment, not whether the claimant could find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). As indicated above, the Veteran retired from his job after 20 years and despite some limitations imposed by his service-connected PTSD, the weight of the probative evidence is against a finding that the Veteran's service-connected disability solely would prevent him from employment when considering his education and experience. The competent and probative medical evidence of record offers detailed specific findings pertinent to the criteria governing the award of a TDIU and is the most probative evidence with regard to evaluating the impact of the Veteran's service-connected disabilities on his employability. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and the impact of the service-connected disability on the Veteran's employability. The 2013 VA examination findings are consistent with the Veteran's admission that he retired on account of a nonservice connected disability notwithstanding the SSA's ultimate determination of what condition rendered the Veteran most disabled. In sum, the evidence does not credibly show that the Veteran is incapable of performing the physical and mental acts required by employment due solely to his service-connected disability. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim for a TDIU rating must be denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial rating in excess of 50 percent for the service-connected PTSD is denied. Entitlement to a TDIU rating is denied. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs