Citation Nr: 1411705 Decision Date: 03/20/14 Archive Date: 04/02/14 DOCKET NO. 10-34 103 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial rating greater than 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating for compensation based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and the appellant ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from March 1971 to October 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2008 and August 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office in Indianapolis, Indiana (RO). The Veteran and the appellant testified at a hearing before a Decision Review Officer at the RO in January 2010, and at a videoconference hearing before the undersigned Veterans Law Judge in January 2011. Transcripts of those hearings are associated with the claims file. The Veteran passed away in October 2011, while his claims were pending before the Board. In November 2011, the appellant filed a claim seeking substitution of the Veteran's claims which were pending before the Board at the time of his death. In April 2012, the Board dismissed the Veteran's appeal based on his death. In October 2013, the RO found that the appellant met the basic eligibility requirements for substitution, and granted her request. See Veterans' Benefits Improvement Act of 2008, Pub. L. No. 110-389, § 212, 122 Stat. 4145, 4151 (2008) (amending the law to allow substitution in cases involving claimants who die on or after October 10, 2008) (codified at 38 U.S.C.A. § 5121A (West Supp. 2012)). As the RO has determined that the appellant meets the criteria for substitution for the Veteran's claims which were pending at his death, she has stepped into the Veteran's shoes with regard to the claims listed on the cover page of this decision. FINDINGS OF FACT 1. Since the initial grant of service connection, the Veteran's PTSD has been manifested by symptoms productive of functional impairment comparable to occupational and social impairment with reduced reliability and productivity. 2. Throughout the rating period on appeal, service connection has been in effect for PTSD, evaluated as 50 percent disabling; tinnitus, evaluated as 10 percent disabling; hiatal hernia, evaluated as 10 percent disabling; and bilateral hearing loss, evaluated as noncompensable. The combined evaluation for the Veteran's service connected disorders was 60 percent. 3. The evidence of record does not show that the Veteran meets the schedular criteria for TDIU, and the evidence does not show that the Veteran was unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 50 percent, but no more, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 2. The criteria for a TDIU have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under 38 U.S.C. § 5103(a), the VA, upon receipt of a complete or substantially complete application, must notify the claimant of the information and evidence necessary to substantiate the claim for benefits. However, in this case the issue on appeal did not stem from an application for benefits, it stemmed from a notice of disagreement to the initial rating assigned by a VA rating decision. Further, 38 C.F.R. § 3.159(b)(3) (effective May 30, 2008) provides that there is no duty to provide section 5103(a) (VCAA) notice upon the Veteran's filing of a notice of disagreement as to the initial rating assignment. 73 Fed.Reg. 23353 - 23356 (April 30, 2008) (as it amends 38 C.F.R. § 3.159 to add paragraph (b)(3), effective May 30, 2008). Rather, such notice of disagreement triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here, as the Veteran was issued a copy of the rating decision, and a statement of the case which set forth the relevant diagnostic code rating criteria. As such, the appropriate notice has been given in this case with respect to the initial rating issue on appeal. The Veteran's service treatment records, VA medical treatment records, and identified private medical records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. Additionally, the Veteran was most recently provided with a VA examination addressing the severity of his PTSD and its effect on his employment in May 2010. Neither the Veteran nor the appellant has indicated that the May 2010 VA examination was inadequate. Moreover, review of the examination report reflects that it is adequate in this case, as it provides a clear picture of the Veteran's disability status sufficient to rate the Veteran's disability under the pertinent rating criteria, and to adjudicate the TDIU claim. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). 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) (2013) requires that the Veterans Law Judge and RO Decision Review Officer (DRO) who conduct a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The VLJ and DRO in this case specifically identified to the Veteran and the appellant, prior to their testimony, the issues on appeal and specifically identified the intended focus of the testimony via questions to the Veteran and the appellant. Additionally, the Veteran demonstrated actual knowledge of what was needed, and provided the appropriate testimony to further clarify all lay bases of evidence. The VLJ and DRO also asked questions to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. Neither the Veteran nor the appellant has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); similarly, neither have identified any prejudice in the conduct of the Board or RO hearing. By contrast, the hearings focused on the elements necessary to substantiate the claims; through his testimony, the Veteran demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. Accordingly, the Board finds that the VLJ and DRO substantially complied with the duties set forth in 38 C.F.R. 3.103(c)(2); any error in notice or assistance by the VLJ and/or DRO at the January 2011 Board hearing and/or January 2010 RO hearing constitutes harmless error. There is no indication in the record that any additional evidence relevant to the issues of entitlement to an initial rating greater than 30 percent for PTSD or entitlement to a TDIU is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). I. PTSD The appellant contends that the Veteran is entitled to an initial rating greater than 30 percent for his service-connected PTSD. The claims file reflects that the Veteran filed a claim seeking service connection for PTSD in January 2005. In April 2008, the RO awarded service connection for PTSD and assigned a 30 percent rating, effective January 26, 2005, under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran filed a notice of disagreement with the assigned rating in December 2008, and in August 2010, he perfected his appeal. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2013). 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. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21 (2013); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). With regard to the Veteran's claim, the level of disability at the time that service connection was granted is of primary importance. Additional staged ratings are appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The current regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan, 16 Vet. App. 436. Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. Pursuant to Diagnostic Code 9411, PTSD is rated 30 percent disabling when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), and chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events). A 50 percent evaluation is warranted when there is 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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 the inability to establish and maintain effective relationships. A maximum 100 percent evaluation is for application when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 61-70 reflects 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, and has some meaningful interpersonal relationships. A GAF score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 41-50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31-40 reveals 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). DSM-IV at 46-47. VA treatment records from November 2004 through November 2006 reveal diagnoses of and treatment for PTSD. The treatment records reflect symptoms including anxiety, frustration, and stress. A December 2004 record reveals that the Veteran had poor short-term memory, poor sleep, crying spells, anhedonia, nightmares, racing thoughts, constant worry, and feelings of hopelessness and helplessness. He noted that he was unemployed, but that he did odd jobs. He stated that he was retired after working for 30 years and that he had mechanic and carpentry skills but only a 9th grade education. He noted a significant impairment in reading and writing skills. Mental status examination revealed the Veteran to appear anxious. Mood was dysphoric and affect was restricted. Thought processes were circumstantial and circumferential. The Veteran was talkative but tended to overexplain his symptoms in an effort to be understood. There was no suicidal ideation and there were no hallucinations. Insight and judgment were limited. The diagnosis was recurrent severe depression. In January 2005, he was alert with good hygiene, calm but dysthymic mood, and flat or blunt affect. He endorsed feelings of hopelessness, shame, and anger. He denied suicidal and homicidal ideation. He noted that he felt better with medication, but reported circular thinking and racing thoughts. Another January 2005 record notes that the Veteran was unwilling to consider doing any kind of work since he had worked in a factory for 30 years and had nothing to show for it. Mental status examination showed the Veteran to be alert with little self confidence. He related logically and coherently, but had few goals for himself. He denied suicidal and homicidal ideation and there were no overt psychotic symptoms. In March 2005, the Veteran reported little motivation and that his medication made him feel heavy and postpone things that needed to be done. The Veteran was alert and related logically, but his judgment and insight were poor. He denied suicidal ideation but had some paranoid thinking. Another March 2005 note indicates that the Veteran endorsed ruminating thoughts of past grievances. He denied suicidal ideation, but reported feeling worthless and hopeless. A May 2005 treatment record reflects that the Veteran was very depressed and unmotivated and slept about 12 hours per day. He noted that he was not working or looking for work, but that a factory was being built right across from his house and that he considered working there. Mental status examinations shoed the Veteran's mood to be irritable and affect to be restricted. Thought processes were concrete. There was no suicidal ideation and no perceptual disturbances. He was alert and oriented with poor insight but fair judgment. Diagnoses included chronic major depression, and a GAF score of 55 was assigned. A May 2005 record reveals that the Veteran was admitted after making suicidal intimations. The Veteran endorsed severe depression and increasing hopelessness. Mental status examination revealed fair eye contact, normal speech, and good communication skills. The Veteran was noticeably hopeless, depressed, and indicated powerlessness over his life. He was fully oriented but slightly anxious. Insight was low but judgment seemed fair. The Veteran denied suicidal ideation at that time. A GAF score of 45 was assigned. A May 2005 hospital discharge summary reveals that the Veteran's son brought him in after some arguments. The Veteran stated that he did not have a job and that he had a lot of stressors at home with his family. He reported that he was depressed and angry, but not suicidal or homicidal. Mental status examination showed limited eye contact, but he was alert and fully oriented. Affect was flat to blunted. Insight was limited and there were no hallucinations. The Veteran was discharged the following day. The discharge diagnosis was major depression, and a GAF score of 65 was assigned. Records from June 2005 note that the Veteran was feeling more positive. Mental status examination showed the Veteran to be adequately groomed with dysphoric or hopeful mood. Affect was restricted and thought process was ruminative. Insight and judgment were fair. The diagnoses were major depression and anxiety disorder. A GAF score of 55 was assigned. An August 2005 record reflects a diagnosis of intermittent explosive disorder. Another August 2005 record reveals increasing depression and anxiety. He reported that he continued to attend anger management therapy. Mental status examination showed the Veteran to be adequately groomed with minimal eye contact. The Veteran appeared tremulous with dysphoric mood. Affect was restricted. Thought processes were logical although ruminative. The Veteran denied suicidal and homicidal ideation and there were no perceptual disturbances reported. Insight and judgment were fair to poor. In December 2005, the Veteran reported depression and anxiety. Mental status examination showed the Veteran to be casually groomed and pleasant. Mood was dysphoric and affect was restricted. Thought processes were logical. The Veteran denied suicidal and homicidal ideation. Insight and judgment were fair. VA treatment records from 2006 reveal continued treatment for PTSD and anger management problems. The treatment records note symptoms of anger, depression, and mistrust of others. Mental status examinations conducted in 2006 reflect adequate and neat grooming; constricted or mobile affect; and euthymic, variable mood. Thought processes were logical and there was no evidence of suicidal ideation. Insight and judgment were fair. GAF scores were 60 and 65. In January 2006, he noted that he was much more inclined to be engaged in activity now that his medications were working. In May 2006, the Veteran noted that he helped his landlord with odd jobs, such as mowing the yard. VA treatment records from 2007 show complaints of depression, anxiety, nightmares, sleep disturbance, and irritability. Mental status examinations reflect neat grooming, mobile affect, and euthymic or anxious mood. Thought process was logical and sequential. There was no suicidal or homicidal ideation. Insight and judgment were fair to good. GAF scores were 65. In April 2007, the Veteran reported improved sleep since starting a new medication. In June 2007, he noted that he was spit on by a man who was holding a grudge against him. He stated that he was enraged, but that he handled the situation well. In July 2007, the Veteran testified at a hearing before the RO. He reported dreams, nightmares, and poor relationships with his family. VA treatment records from 2008 show complaints of irritability towards his wife and family, nightmares, sleep disturbance, anger. Mental status examinations revealed neat or adequate grooming; euthymic mildly dysphoric, or mildly anxious mood; and mobile affect. Thought processing was logical but occasionally ruminative. There was no suicidal ideation and no psychosis. Insight and judgment were good. GAF scores of 65 and 67 were assigned. In January 2008, the Veteran underwent a VA psychiatric examination. The Veteran reported that he lived with his wife and was retired from a 30-year career. The Veteran complained of memory problems, anger management problems, depression, and interpersonal problems with his family. He also noted nightmares, poor sleep, and social withdrawal. He reported that he had been arrested six times with charges of driving under the influence, domestic violence, forced entry into his previous home, battery towards a cousin, and invasion of privacy. He explained that he worked for a factory for 30 years as a machine operator and a mechanic. He retired in 2000 when the plant closed and has not worked since then. He stated that he had been married three times. He was married to his first wife from 1969 to 1994, to his second wife from 2001 to 2002, and to his third wife in 2007. He reported a close relationship with his current wife and stated that they enjoyed going out to restaurants. He stated that they were active in their church and that he enjoyed going to church dinners with his wife. He reported that he was getting to know his wife's family and that he visited with them once a week. He noted a close relationship with his mother. He described strained relationships with his children, and noted that he had three children, but that one of his sons was murdered. He also reported that he was starting to reestablish positive relationships with his two biological children. The Veteran stated that he had one good friend, Dan D., who he had known since he was a teenager. He indicated that he saw Dan every other week. The examiner noted that the Veteran had a history of batteries involving legal convictions. He also had a history of suicidal ideation and was hospitalized in 2005. Mental status examinations revealed the Veteran to be neatly dressed with good grooming and hygiene. Eye contact was good and there was no inappropriate behavior. The Veteran was alert and fully oriented with average memory and concentration, although the Veteran noted some problems with memory. Insight and judgment were average, although there was evidence of learning difficulties. Speech was fluent, normal rate, and well articulated. Speech patterns were logical, relevant, coherent, and goal directed. The Veteran denied psychotic symptoms, including hallucinations and delusions. Mood was free of significant depression or anxiety. Affect was appropriate. The Veteran became angry at times and appeared to be somewhat controlling. The Veteran denied impulse control problems as well as suicidal and homicidal ideation. He denied sleep impairment and did not report any panic attacks. No obsessive or ritualistic behaviors were reported. The diagnoses were PTSD, alcohol dependence in remission, cannabis abuse in remission, and major depressive disorder in remission. A GAF score of 65 was assigned. The examiner stated that the Veteran was suffering from a mild case of PTSD. VA treatment records from 2009 reveal complaints of irritability, anger outbursts at his wife, depression, nightmares. Mental status examinations regularly showed fairly good grooming and good eye contact. The Veteran was alert and attentive with euthymic affect. He was fully oriented and memory was not impaired. Mood was anxious, depressed, or good. There was no aberrant behavior. Thought processing was logical and responses were coherent and goal directed. There was no suicidal or homicidal ideation. The Veteran denied delusions and hallucinations. Insight and judgment were adequate. In June 2009, the Veteran underwent another VA examination. The Veteran complained of difficulty managing his anger and sadness over not seeing his grandchildren regularly. The examiner noted that, overall, the Veteran's mental health problems appeared to be of mild severity. The examiner also reported that the Veteran reported a relatively average capacity for adjustment. The Veteran reported that, in 2000, he retired after a 30-year career as a mechanic. He noted that he received a pension from the company. He stated that he had been married three times and had three children, one of whom was deceased. He reported a close and loving relationship with his wife. He noted that they were active at church together and that they took a vacation together the previous year. He stated that he had a few friends at church, and that they occasionally went out to dinner with them after services. He also noted that he and his wife enjoyed going to local events together, such as the local fair that they attended the previous week. He indicated that he saw his step-children regularly and was working on reestablishing a relationship with his son. He reported a close relationship with his mother, and indicated that he saw his sisters on a somewhat regular basis. The Veteran stated that he enjoyed fishing, but that he had not gone that year. He reported that he also enjoyed gardening. The examiner stated that the Veteran reported average psychosocial functioning. The Veteran denied recent problems with the legal system, suicidality, aggressivity, or substance abuse. Mental status examination showed the Veteran to be neatly groomed with good hygiene. He was able to independently care for his personal hygiene and other basic activities of daily living. He had good eye contact with no inappropriate behavior. He was calm, relaxed, alert, and fully oriented. Memory and concentration were average with no significant deficits. Insight and judgment were average. Speech was fluent, of normal rate, and well articulated. Speech patterns were logical, relevant, coherent, and goal directed. He denied any psychotic symptoms, such as hallucinations and delusions. Mood was free of significant anxiety and depression. The Veteran became sad when discussing his relationship with his biological daughter and grandchildren. Affect was appropriate. He denied any impulse control problems as well as suicidal or homicidal ideation. He did not report sleep disturbance, panic attacks, or obsessive or ritualistic behavior. The diagnoses were mild PTSD, alcohol dependence in remission, cannabis abuse in remission, and depressive disorder, and a GAF score of 65 was assigned. The examiner noted that a GAF score specific to PTSD would be 66, and that the Veteran's PTSD had a mild effect on occupational and social functioning. In a December 2009 lay statement, the appellant reported that the Veteran was very uptight and nervous. She noted that he had anger control problems and outbursts of anger. She also reported that he was suspicious of people, and that she saw him checking his surroundings. She described the Veteran as a loner, and indicated that he did not like being around big crowds. She said that the Veteran was isolated and withdrawn, and that he would not go out shopping with her. She reported that, if the Veteran did accompany her out for dinner, he would always sit near a window so that he could see outside. She noted that Danny D. was the Veteran's only close friend. The appellant stated that the Veteran had problems sleeping as well as nightmares where he hollered and jerked in his sleep. She noted that the Veteran avoided the news, and that he had constant depression, insecurity, short-term memory trouble, and irritability. She indicated that he had an exaggerated startle response and avoided fireworks, and that he had problems concentrating. She noted that the Veteran did not handle stress well, and that he had panic attacks, but she could not recall how frequently they occurred. She stated that he avoided trauma-related stimuli. In a December 2009 statement, Danny D. reported that he knew the Veteran for 46 years, and that he worked with him for 26 years. He stated that they were neighbors for 12 to 13 years, and friends. He also indicated that he was the union representative at their place of employment, and that the Veteran had a lot of issues at work. He stated that people were afraid of the Veteran and avoided him as much as possible, as he was intimidating. He had problems dealing with authority and did not like to take orders. He also missed a lot of work, often two to three days in a row. Danny stated that he represented the Veteran several times to help him get out of trouble caused by his temper and anger outbursts. Danny noted that he was a loner with no close friends, and that he was suspicious of people and paranoid. Danny recalled one instance where the Veteran lost his temper in a fit of rage at his wife and threw a bowling ball on the floor, shattering it to pieces. He indicated that the Veteran had severe mood swings, was always irritable, and always depressed. He noted that the Veteran's short-term memory was poor, and that he had an exaggerated startle response, and difficulty concentrating. Danny noted that the Veteran made some comments indicating suicidal ideation, but never mentioned any plans. The Veteran had repetitious speech, staring spells, impaired judgment, and thought processing problems. In a December 2009 lay statement, Belinda W., the Veteran's sister, reported that the Veteran had frequent nightmares, was a loner, and had a history of alcohol and drug use following his return from Vietnam. She stated that the Veteran was very short-tempered and irritable, and often went off in a fit of rage. She noted that the Veteran was paranoid, avoided crowds, and didn't trust people. She reported that he stared a lot and nervously paced the floor. She indicated that he was not interested in the world around him, that his long-term memory was bad, that he did not like loud noises, that he was jumpy, and that he had disturbed sleep. She stated that he used to enjoy hunting and fishing, but that he stopped doing those things when he returned from service. She reported that he had trouble concentrating, isolated himself frequently, and was very moody. She stated that he retired from work when his employer closed, and that he had not worked since. She noted that the Veteran had no close friends, that thought processing was difficult, that he was very argumentative, and that he no longer enjoyed the hobbies that he used to. During a January 2010 hearing before the RO, the Veteran reported irritability, variable mood, verbal abuse towards his wife, short temper, and poor relationships with his children and grandchildren. He stated that he had anger outbursts and was arrested for violent outbursts when he kicked the door in at his old house in 1995. He reported that he worked as a maintenance mechanic for 30 years, but that he had absenteeism and outbursts at work. He noted that his friend, a union representative, helped to protect his job during those times. He indicated that he used to enjoy fishing, but no longer went fishing. He stated that his psychiatric medications caused drowsiness. He reported a poor memory and lack of ambition. He stated that he was nervous and agitated, and that he had no friends. He indicated that he could not control his temper, that he was easily enraged, and that he did not trust others. The appellant testified that the Veteran had angry outbursts around her children and that she felt as though she was walking on eggshells. She indicated that he did not help much around the house, that he was constantly angry, depressed, anxious, and confused. She also stated that the Veteran had an exaggerated startle response. The Veteran testified that he retired from his job in 2000 because the plant that he was working for closed. The Veteran's representative noted that the Veteran's symptoms included introversion, anger outbursts, paranoia, and mistrust of others. VA treatment records from 2010 show complaints of irritability, depression, nightmares, and poor sleep. The Veteran reported that his medication made him sleepy. Mental status examinations showed good grooming and hygiene, good eye contact , and good, restricted, or mildly dysphoric affect. The Veteran was fully oriented. Speech was normal. Mood was depressed and anxious. Thought process was organized and there was no suicidal or homicidal ideation. There were no delusions or hallucinations. GAF scores of 67 were assigned. In May 2010, he indicated that he was less anxious, less depressed, and not irritable. In August 2010, the Veteran reported that he felt good since the adjustment of his medications. He indicated that his anxiety and depressive symptoms subsided, and that he had a friend in his wife. In May 2010, the Veteran underwent another VA examination. He complained of mistrusting others, increased agitation, irritability, frequent nightmares, poor sleep, and verbal abuse of others. He was also diaphoretic and hypervigilant with hyperarousal, and increased startle response. He noted that his symptoms occurred two to three times per week, and were moderate in severity. He indicated that he was not working, in part due to his psychiatric symptoms, including agitation, irritability, and conflict with co-workers. The Veteran stated that he had a legal history, including two charges of driving under the influence and one charge of battery. He reported that he did not get to see his children or grandchildren. He noted one friend who he conversed with infrequently. He reported sleep disturbance, but also noted that he slept all day long. He related a history of verbal and physical assaultiveness with co-workers and supervisors which resulted in his termination from employment multiple times before being reinstated. He also noted that he attempted suicide one time by hanging in the presence of his daughter and ex-spouse. The examiner reported that the Veteran's PTSD symptoms included verbal and physical aggression, increased agitation, hypervigilance, hyperarousal, sleep disturbances, nightmares, increased withdrawal, no socialization, avoidance of family functions, night wakings, re-experiencing trauma-related stimuli, avoidance of trauma-related stimuli, physiological arousal, flashbacks, and sitting in the back of restaurants in order to see the entire premises. Mental status examination revealed normal thought processes and communication, no delusions or hallucinations, a history of inappropriate behavior, a history of suicidal thoughts and intent, and no homicidal ideation. The Veteran was able to maintain minimal personal hygiene and other basic activities of daily living and was fully oriented. There was memory impairment to a mild or moderate degree on a daily basis. There was no obsessive or ritualistic behavior and speech was normal. The Veteran reported panic attacks three to four times per week. There was moderate daily depression which caused social isolation. There was also daily severe anxiety resulting in increased withdrawal and decreased socialization. There was no evidence of impaired impulse control. No other symptoms were noted. The diagnoses were PTSD, generalized anxiety disorder, and alcohol abuse. A GAF score of 50-55 without suicidal ideation was assigned. The examiner concluded that the Veteran's PTSD resulted in deficiencies in most areas, including work, school, family relations, judgment, thinking, and mood. The examiner explained that his symptoms resulted in alienation at his work place, home, dissolution of his previous marriage, and substance abuse disorder. His presentation and behaviors disrupted his current marriage, and the PTSD exacerbated his sleep disturbance, nightmares, agitation, and aggressive behaviors. The PTSD symptoms were severe enough to interfere with occupational functioning. During a January 2011 hearing before the Board, the Veteran's representative stated that he felt that two of the VA examinations in the record were inadequate and that the examiner failed to provide a valid medical analysis. The representative requested that the Board defer to the May 2010 VA examination for an accurate assessment of the Veteran's symptoms. The Veteran testified that his symptoms included irritability, depression, social isolation, short temper, anger outbursts, mistrust of others, poor sleep, nightmares, night sweats, exaggerated startle response, poor memory for dates and telephone numbers, avoidance of trauma-related stimuli, and a history of suicide attempts. The Veteran testified that he was irritable with his wife, that he attended church with his wife but did not enjoy going, that he did not socialize at church, that he had a poor relationship with his children and grandchildren, that he did not leave the house often, and that he verbally abused his wife. He noted that he was married three times, and that his PTSD affected all of those relationships. He stated that he did not trust anyone, even his brother. He described a history of a suicide attempt in 2005. He stated that he last worked in 2000 as a maintenance mechanic at a glass factory. He worked there for 30 years and retired when the factory closed. He noted that his friend worked as the union representative at the factory, and that he protected his job several times due to anger outbursts and inability to get along with others at work. He stated that he did not believe that he was able to work because he did not get along with others. He also noted that his other disabilities, including arthritis and poor knees affected his ability to work. He did not believe that his hearing loss or hernia impacted his ability to work. The appellant testified that the Veteran frequently lost his temper, was irritable, and verbally abusive towards her and his grandchildren. She noted that the Veteran had anger outbursts. She also reported that the Veteran had sleep disturbances, and that he woke up frequently at night with night sweats. She also indicated that he had a poor memory for dates. She stated that he did not enjoy attending church with her and that he was unable to handle stress. She explained that the Veteran took a lot of medication for his psychiatric disability, and that she did not believe that he could hold down a job due to the side effects of the medication, which included making him sleepy during the day and impacting his judgment. The Veteran's representative noted that the Veteran had a 9th grade education. The Veteran's current 30 percent evaluation contemplates functional impairment comparable to 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). 38 C.F.R. § 4.130, Diagnostic Code 9411. As noted above, GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242. The Veteran's GAF scores of 45 and 50 reflect serious symptoms or serious impairment in social, occupational, or school functioning. The Veteran's GAF scores of 55 and 60 show moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Veteran's GAF scores of 65, 66, and 67 indicate some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. See DSM-IV at 46-47. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2013); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). Accordingly, based on the analysis of the evidence as outlined below, the Board finds that the evidence supports an initial rating of 50 percent, but no more, for the Veteran's service-connected PTSD. Since the initial grant of service connection, the Veteran reported symptoms including depression, sleep disturbance, nightmares, hypervigilance, flashbacks, social isolation, and exaggerated startle response. He also endorsed poor concentration, avoidance of trauma-related stimuli, anger outbursts, irritability, detachment and estrangement from others, memory and concentration problems, anxiety, avoidance of crowds, panic attacks, suicidal ideation with one attempt, and lack of motivation. The Veteran reported that he always sat where he could see the entire restaurant when dining out. He frequently stated that he had poor relationships with his family and that he verbally abused his wife. The evidence indicates that he was suspicious of people and paranoid, he always checked his surroundings, he had severe mood swings, he had repetitious speech, he had staring spells, and he had fits of rage. Some evidence indicates that he had a good relationship with his wife. However, the majority of the evidence suggests that he relied on her to get by, but was verbally abusive towards her and socially isolated himself. The evidence also shows that the appellant was his third wife, and that his PTSD symptoms negatively impacted his previous marriages as well. The Veteran stated that he had significant difficulty getting along with his co-workers, and although he was able to keep his job until the factory closed, this was because his friend, the union representative, came to his aid when he was in trouble. The medical evidence shows that the Veteran was alert and fully oriented. His mood was anxious, dysphoric, depressed, irritable, euthymic, or variable. Affect was restricted, flat, blunt, mobile, or appropriate. Thought process was sometimes circumstantial, but other times concrete. There was no evidence of hallucinations or delusions. Insight and judgment were fair, good, limited, or poor. Thought content reflected paranoid thinking and ruminative thoughts on several occasions, and was other times normal. Eye contact was fair, good, minimal, or limited. Grooming and hygiene were adequate. There was no evidence of obsessive or ritualistic behavior and no reported impulse control problems aside from the fits of rage. There was a history of inappropriate behavior and one suicide attempt. After a thorough review of the evidence of record, the Board concludes that the evidence of record demonstrates that the Veteran's symptoms were productive of functional impairment comparable to that contemplated for a 50 percent evaluation for PTSD, as there is evidence of flattened affect, circumstantial speech, impairment of short- and long-term memory, disturbances in motivation or mood, and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. However, an evaluation in excess of 50 percent is not for assignment in this case. While there is evidence of suicidal ideation and some impaired impulse control, there is no evidence of 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; spatial disorientation; neglect of personal appearance and hygiene; or difficulty in adapting to stressful circumstances. Further, while the Veteran certainly demonstrated difficulty establishing and maintaining effective relationships, the evidence does not demonstrate an inability to do so. Id. Although the evidence of record may demonstrate some of the symptoms contemplated in a 70 percent evaluation, the Veteran's disability picture more closely corresponds to the requirements for a 50 percent evaluation. Thus, as the evidence does not more nearly approximate an evaluation greater than 50 percent, an increased evaluation in excess of 50 percent is not warranted for the Veterans PTSD. The Board has also considered the Veteran's symptoms of sleep disturbance, nightmares avoidance of trauma-related stimuli, exaggerated startle response, flashbacks, hypervigilance, anxiety, avoidance of crowds, irritability, and mood swings. While those symptoms certainly contribute to the impairment caused by the Veteran's PTSD, they were not shown to be productive of functional impairment comparable to occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood sufficient to warrant an evaluation in excess of 50 percent. Mauerhan, 16 Vet. App. 436. Accordingly, and for the foregoing reasons, an initial evaluation greater than 50 percent for service-connected PTSD is not warranted at any time during the rating period on appeal. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20 , 4.27 (2013). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's PTSD is not so exceptional in nature as to render the rating for that disorder inadequate. The criteria by which that disorder is evaluated specifically contemplate the level of impairment caused by that disability. Id. As demonstrated by the evidence of record, the Veteran's PTSD is manifested by dysphoric, anxious, irritable, euthymic, or depressed mood; restricted, flat, or blunt affect; depression; sleep disturbance; nightmares; flashbacks; social isolation; hypervigilance; exaggerated startle response; poor memory and concentration; avoidance of trauma-related stimuli; anger and irritability; suicidal ideation; limited insight and judgment; panic attacks; circumstantial thought processes; paranoid thinking; and ruminating thoughts. The evidence also shows that the Veteran was alert and fully oriented; had good grooming and hygiene; no hallucinations or delusions; and no obsessive or ritualistic behavior. When comparing this with the symptoms contemplated in the Rating Schedule, the Board finds that the schedular evaluation regarding the Veteran's PTSD is not inadequate. An evaluation greater than 50 percent is provided for greater functional impairment due to manifestations of PTSD, but the medical evidence reflects that such level of functional impairment is not present in this case. Therefore, the schedular evaluation is adequate and no referral is required. After review of the evidence of record, there is no evidence of record that would warrant a rating in excess of 50 percent for the Veteran's service-connected PTSD at any time during the period pertinent to this appeal. 38 U.S.C.A. 5110 (West 2002); see also Fenderson, 12 Vet. App. at 126; see also Hart, 21 Vet. App. 505. While there have been day-to-day fluctuations in the manifestations of the Veteran's PTSD, the evidence shows no distinct periods of time since service connection became effective, during which the Veteran's PTSD has varied to such an extent that a rating greater or less than 50 percent would be warranted. Cf. 38 C.F.R. § 3.344 (2013) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). II. TDIU The appellant contends that, prior to his death, the Veteran was unemployable as a result of his service-connected disabilities. During a January 2011 hearing before the Board, and in a January 2010 hearing before the RO, the Veteran testified that he worked at a factory as a maintenance mechanic for approximately 30 years. In 2000, he retired when the plant closed. He alleged that his PTSD impacted his ability to get along with co-workers, that he had anger outbursts and absenteeism from work due to his PTSD, and that as a result of this as well as his arthritis, he was unable to work. The appellant added that the Veteran's psychiatric medications made him sleepy during the day and impacted his judgment, rendering him unemployable. A total rating for compensation purposes based upon individual unemployability is warranted when the schedular rating is less than total and the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. A total rating for compensation purposes based upon individual unemployability benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for a total rating for compensation purposes based upon individual unemployability; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Individual unemployability must be determined without regard to any nonservice-connected disabilities or the Veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19 (2012); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Service connection is currently in effect for PTSD, rated as 50 percent disabling; tinnitus, rated as 10 percent disabling; hiatal hernia, rated as 10 percent disabling; and bilateral hearing loss, rated as noncompensable. The combined evaluation for the Veteran's service connected disorders is 60 percent. As such, the Veteran does not meet he schedular criteria for a total rating for compensation based upon individual unemployability. 38 C.F.R. § 4.16(a). Nonetheless, the Board must consider whether the evidence of record warrants referral to the Director of Compensation and Pension Service for entitlement to a total rating for compensation purposes based upon individual unemployability on an extraschedular basis under the provisions of 38 C.F.R. § 4.16(b), where a veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). In this case, the evidence does not show that the Veteran was unemployable due to his service-connected disabilities. 38 C.F.R. § 4.16(b). The record reveals numerous instances where the Veteran reported that he retired from his position as a maintenance mechanic after working for 30 years because the plant closed. The Board acknowledges the lay statement submitted by Danny D., which reflects that as the union representative at the Veteran's prior job he had to represent him and "bail him out of jams he got into." The Board also acknowledges the evidence which reflects that the Veteran had difficulty getting along with his co-workers, increased absenteeism, and anger outbursts at work. While this evidence suggests that the Veteran had difficulty maintaining a job, the evidence also shows that he was able to work for 30 years after service with PTSD before retiring with a pension. The evidence does not reflect that the Veteran attempted to and was unable to obtain a job after his retirement. In fact, the Veteran reported that he was "unwilling" to consider doing any kind of work, since he worked in a factory for 30 years and had nothing to show for it. Moreover, there is no medical opinion of record indicating that the Veteran was unemployable due to his service-connected disorders. A total rating for compensation purposes based upon individual unemployability is granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retention of substantially gainful employment. 38 C.F.R. § 4.16(a). A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose, 4 Vet. App. at 363. While the Veteran's service-connected disabilities may have a negative effect on employability, the sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The evidence of record does not demonstrate that the Veteran's service-connected disabilities precluded him from securing or following any type of substantially gainful occupation. The Veteran does not meet the percentage criteria under 38 C.F.R. § 4.16(a) and the evidence does not otherwise demonstrate an inability to secure or follow a substantially gainful occupation due to his service-connected disabilities. Thus, the Board finds that the RO's decision not to refer this issue to the Director of Compensation and Pension Service for extraschedular consideration of a total rating for compensation purposes based upon individual unemployability was correct. For the forgoing reasons, a total rating for compensation purposes based upon individual unemployability is not warranted. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim for TDIU, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). ORDER Entitlement to an initial rating of 50 percent, but no greater, for service-connected PTSD is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a TDIU is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs