Citation Nr: 1530389 Decision Date: 07/16/15 Archive Date: 07/24/15 DOCKET NO. 11-21 641 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jeremy J. Olsen, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from March 1968 to March 1970. He is the recipient of the Purple Heart and the Bronze Star. The Veteran also served in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina (hereinafter Agency of Original Jurisdiction (AOJ)), which denied a rating in excess of 50 percent for service-connected PTSD. A March 2010 AOJ rating decision awarded a 70 percent disability rating for PTSD, effective October 16, 2009 (the date of claim). Regarding the characterization of the claims on appeal, the Veteran is service-connected for PTSD only. During the appeal period, the Veteran filed a claim of entitlement to TDIU due to PTSD. The AOJ denied this claim in a June 2011 rating decision. In July 2011, the Veteran filed a notice of disagreement with this determination, and the AOJ issued a statement of the case in July 2014. In a December 2014 Statement of Accredited Representative in Appealed Case, the Veteran's representative provided argument on the TDIU issue. The Board assumes jurisdiction over the TDIU issue as part and parcel of the claim for an increased rating for PTSD. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). For administrative purposes, the Board has listed the TDIU issue as a separate claim on the title page. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. The Board notes that, in addition to VBMS, there is a separate electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the documents in Virtual VA reveals the documents therein are either duplicative of those contained in the VBMS or irrelevant to the claim on appeal. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's PTSD has not more nearly approximated total occupational and social impairment. 2. For the entire appeal period, the Veteran's PTSD has prevented him from obtaining and maintaining substantially gainful employment consistent with his educational and vocational experience. CONCLUSIONS OF LAW 1. The criteria for a schedular rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2014). 2. The criteria for entitlement to TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's 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 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). 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 a claim for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). 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 AOJ decision on the claim for VA benefits. As addressed below, the Board grants the claim of entitlement to TDIU in full. As such, any duty to notify or duty to assist errors with respect to this claim have resulted in harmless error. With respect to the increased rating claim for PTSD, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a letter dated October 2009, sent prior to the rating decision issued in February 2010, advised the Veteran of the evidence and information necessary to substantiate his claim for an increased rating for PTSD. The letter advised him of his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the letter advised him of the information and evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was also afforded VA examinations in December 2009, March 2011, August 2011 and December 2013 in conjunction with his claim for an increased disability rating for PTSD. Neither the Veteran nor his representative has alleged that any of the examinations are inadequate for adjudication purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected PTSD, as they include an interview with the Veteran and a full mental status examination, and all contain a review of the record, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary. 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 claim. II. Analysis A. PTSD The Veteran filed his claim for an increased rating for PTSD in October 2009. A March 2010 AOJ rating decision granted a 70 percent rating for service-connected PTSD effective to the date of claim. The Veteran contends that he is entitled to a 100 percent schedular rating. 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 entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, 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. The Veteran's PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula For Mental Disorders, to include PTSD, a 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation is assignable where 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit has held, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms [,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. In addition to evidence regarding the Veteran's symptomatology and its impact on his social and occupational functioning, a Global Assessment of Functioning (GAF) score is another component considered to determine the entire disability picture for the Veteran. The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). The GAF score is based on all of the Veteran's psychiatric impairments. A GAF Scale score of 41 to 50 indicates 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); and a GAF score between 51 and 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). The Board notes that a GAF score need not be accepted as probative if it is determined that the score does not reflect the overall psychiatric disability picture at the time of the examination. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995) (it is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others). However, the probative value of the GAF scores will be considered in light of the other evidence of record. Here, in an October 2008 VA treatment note, the Veteran indicated he was experiencing difficulty with his PTSD symptoms. He indicated he was not sleeping well and was "on edge" around his grandchildren. A suicide screen was negative, and the clinician assigned a GAF score of 46. A VA treatment note later that month showed the Veteran had participated in a veteran support group concerning PTSD-related topics. A suicide screen was negative and a GAF score of 49 was assigned. In November 2008, the Veteran was seen at VA for an unrelated medical issue. At that time, he denied suicidal or homicidal intent. Problems with insomnia were noted. A depression screen showed the Veteran experienced little interest or pleasure in doing things for several days, and that he felt down, depressed and hopeless for several days. However, his overall score indicated a negative screen for depression. In conjunction with that visit, the Veteran was seen by his VA psychiatrist, who noted continued problems with sleep. The Veteran denied suicidal or homicidal ideation, reported avoiding crowds, finding himself easily irritated, and easily startled at loud noises. He was found to be alert, attending and cooperative with a subdued mood. The Veteran's affect was mildly constricted, with decreased energy and linear, coherent thoughts. No psychotic thoughts were noted. The psychiatrist assigned a GAF of 45. Later that month, the Veteran attended the support group and was noted to be working on communication and impulse control. A suicide screen was negative and a GAF score of 49 was assigned. In December 2008, the Veteran participated in the VA support group. His mood was noted to be stable, with no suicidal or homicidal ideation. A suicide screen was negative. The Veteran was seen by a VA clinician in January 2009. At that time, he was found to have capacity for empathy, proper impulse control, intelligence, judgment, social skills, insight, and communication skills. The clinician found the Veteran had the capacity for stable relationships. His mood was stable, no suicidal or homicidal ideation was noted, and a GAF score of 49 was assigned. Later that month, the Veteran attended the VA support group and reported his continued struggle with dreams, mood swings and nightmares. His mood was considered stable and he denied suicidal or homicidal ideation. A GAF score of 50 was assigned. The Veteran attended the VA support group on two occasions in February 2009. The corresponding VA treatment notes indicate the Veteran continued to deny any suicidal or homicidal ideation, and he was assigned GAF scores of 50 and 49. In February 2009 the Veteran was also seen by his VA psychiatrist with complaints related to an inability to sleep. The Veteran denied any suicidal or homicidal ideation, and described isolating himself from others in order to avoid conflict. Both the Veteran and his wife indicated that the Veteran was irritable. The VA psychiatrist assigned a GAF score of 45. A March 2009 VA treatment note indicates the Veteran continued to experience depression and insomnia. He denied suicidal or homicidal intent. A suicide screen performed later that month in conjunction with the Veteran's participation in his support group was negative. At that time, the Veteran reported working on impulse control issues and coping skills. He reported experiencing mood swings, hyperarousal issues and nightmares. A GAF score of 47 was assigned. A May 2009 VA treatment note indicates the Veteran continued to participate in the support group, and was working on issues with impulse control. A suicide screen was negative and a GAF of 49 was assigned. In June 2009, the Veteran attended the VA support group and was noted to be receptive. He indicated a desire to work on his social isolation issues. A suicide screen was negative and a GAF score of 48 was assigned. A July 2009 VA treatment note showed the Veteran experienced normal impulse control, judgment, social skills, frustration tolerance, insight and communication skills. He continued to work on the development of effective coping skills to increase his awareness of anxiety before such feelings get out of control. A GAF score of 48 was assigned. In a September 2009 VA treatment note, the Veteran reported worrying about taking care of his family and financial obligations. He was experiencing problems staying asleep, and experienced nightmares related to the war 2 to 3 times per week. The Veteran indicated he experienced irritability and isolation. His wife no longer wanted him to drive due to the aggravation, and his grandchildren were no longer allowed to visit because they made too much noise. The clinician noted the Veteran appeared to be more distant from his wife and family. He was assigned a GAF score of 46. Later that month, a VA treatment note reflected a negative suicide screen and that the Veteran continued to isolate himself, socially, as well as experience impulse control and trust issues. The Veteran was afforded a VA PTSD examination in December 2009. The examiner reviewed the Veteran's claims file in its entirety. She noted the Veteran attended group therapy, and had never been hospitalized for psychiatric problems. The Veteran was noted to have difficulties with sleep, getting only 4 hours per night and having difficulty maintaining sleep because of frequent nightmares. The Veteran reported experiencing flashbacks, which he described as the nightmares. The Veteran reported hypervigilance, exaggerated startle response to very loud noises, difficulty in crowds, anger, irritability, decreased socialization, difficulty with trust, a depressed mood, some feelings of hopelessness and suicidal ideation in the past. The Veteran reported memory problems over the past year. He indicated avoiding war movies and driving near wooded areas because it reminded him of Vietnam. The Veteran's wife had not slept in the same bed as Veteran for the past year, due to his restlessness and his response if she were to try to awaken him, due to his exaggerated startle response. The Veteran admitted to experiencing anger and irritability toward his grandchildren and responding by being rude to them. The examiner noted the Veteran retired at age 62 from a waste management company, although the Veteran could not remember how long he had worked there. The Veteran reported a history of problems with anger on the job and an inability to get along with coworkers. On mental status exam, the examiner found the Veteran to be alert and oriented times 4. His thought process was linear, affect was blunted and speech was fluent. The Veteran presented some difficulty with the recall of personal information and with attention and memory on the mental status examination. The Veteran denied suicidal or homicidal ideation. The examiner noted that the Veteran reported poor motivation to complete his activities of daily living (ADLs), with his wife having to remind him to wash himself. He sometimes forgot to take his medication. Overall, the examiner concluded that the Veteran was demonstrating severe impairment of functioning due to symptoms of PTSD, including severe impairment of social functioning and severe impairment in occupational functioning. The examiner assigned a GAF score of 46. A December 2009 note indicated the Veteran continued to sleep poorly, felt very detached from others, was increasingly irritable and unable to concentrate. He denied suicidal or homicidal ideation, and had a GAF score of 48. A February 2010 VA treatment note indicated no suicidal or homicidal ideation, a negative suicide screen, and a GAF score of 45. One month later, in March 2010, the Veteran indicated he had experienced suicidal ideation, which was attributed to the denial of his claim for an increase in his PTSD disability rating. He reported no plan at that time. In April 2010 the Veteran reported experiencing intrusive thoughts, insomnia, and worry. He denied any suicide risk, or suicidal or homicidal ideation. Weekly VA treatment notes for April through August 2010 continued to show regular testing for suicide risk that resulted in a negative result, and a continuous denial of suicidal or homicidal ideation on part of the Veteran. In an August 2010 VA treatment note, the Veteran discussed his work history and reported that he had retired from his job as soon as he was able to, because going to work was a chore. He also indicated that he kept to himself while at work, and that he was at odds with his co-workers. The Veteran stated that he never made any friends or participated in outside activities with his co-workers for worry of losing his temper and hurting someone. The Veteran reported experiencing hypervigilance during the day as well as a hyperstartle response to loud unexpected noises or when approached from behind. The clinician noted the Veteran continued to be irritable and isolate from others. The Veteran denied suicidal and homicidal ideation at that time. In a second August 2010 VA treatment note, the Veteran reported experiencing night sweats, anger issues and mood swings. He indicated he felt so angry at times that he felt he could "tear a man apart." The Veteran recounted incidents of road rage. He denied suicidal or homicidal ideation and reported experiencing sleeping problems, issues with trust, hyperarousal issues and mood swings. In a November 2010 VA treatment note, the Veteran reported mood swings, night sweats and social isolation, although he was actively seeing emotional improvement. The clinician assigned him a GAF score of 49. A January 2011 VA treatment note indicated the Veteran was experiencing some issues with his ADLs. Specifically, the Veteran's meals were prepared by others; he expressed difficulty with transportation, and difficulty using a telephone. Most other ADLs were normal. In a March 2011 VA treatment note, the Veteran stated he been more depressed and isolated as of late, but could not name a reason why. He indicated that his nightmares, startle response and hypervigilance had all increased. His mood was noted to be anxious and depressed. The Veteran denied auditory or tactile hallucinations, but felt he experienced some incidents where he thought he saw someone out of the corner of his eye who was not there when he looked directly at them. The clinician attributed this to the Veteran's hypervigilance rather than to actual hallucinations. The Veteran denied suicidal or homicidal thoughts, plans or intent, but did state that he noticed an increase in what he termed "bad thoughts" more lately. Later that month, the Veteran was assigned a GAF score of 44 and was noted to experience restless sleep and a hyperstartle response. He reported feeling some suicidal ideation, and feeling hopeless and helpless. The Veteran underwent a VA PTSD examination in March 2011. At that time, in reviewing the Veteran's claims file, the examiner noted the Veteran's well-documented history of PTSD. However, on examination, the Veteran was unable to provide specific details of his experiences while in war, or the content or frequency of his nightmares. The Veteran could not describe what he meant by the term "panic attack," and contradicted himself multiple times when discussing the nature of his PTSD symptoms. He had poor recall of many details of his personal life, including his age, the city in which he was born, the name of his high school, when he was married, how long he worked for his last employer, and when he quit drinking. The examiner noted that while the Veteran's clothes were "filthy," his hygiene was not poor. The Veteran denied that his wife had to remind him to bathe. On mental status examination, the examiner found the Veteran to be alert, with blunted affect. He was a poor historian and was consistently vague and frequently contradicted himself. The examiner indicated that he doubted the Veteran was providing an accurate report of his symptoms and was compelled to note that he believed the Veteran to be displaying "Ganser-type" responses. The Board notes that Ganser syndrome is defined as the "giving of inappropriate, ridiculous or approximate answers to questions...most commonly seen in malingering [persons] feigning psychosis." See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1831 (32nd Ed., 2012). Based on this, the VA examiner was unable to render a diagnosis or assign functional limitations without resorting to speculation. In April 2011, the Veteran reported experiencing mood swings and increased nightmares. The VA clinician noted that the Veteran was dressed neatly and was clean. In May 2011, the Veteran reported increased nightmares. In addition, he continued to experience mood swings, hyperarousal issues, sleeping problems and nightmares. In a May 2011 VA nursing note, the Veteran indicated feelings of hopelessness about the present and the future; however, he had no suicidal thoughts or plan at that time. He reported that his PTSD symptoms had increased since he stopped working, as work had been a distraction. He reported increased anxiety levels, sleep disturbances and war-related nightmares. The Veteran reported sleeping no more than 4 hours a night, experiencing hypervigilance, feeling irritable, isolating from others and avoiding any war-related discussion. He described isolation as sometimes including from his family. The Veteran indicated he had been skipping meals, medications and showers, as well. The Veteran reported making no new friends. He stopped going to church. The Veteran indicated a desire to return to work and better provide for his family, but remained anxious about losing his temper and hurting someone if he did. Despite this, the Veteran reported problems with the law, or experiencing any suicidal or homicidal ideation. In July 2011, the Veteran reported experiencing anxiety, mood swings, nightmares, hyperarousal issues, and impulse control issues when around people. He was dressed neat and clean. The clinician noted that the Veteran had never appeared unkempt in any individual therapy or group session in the 4 years she'd been treating him. The Veteran indicated he had thoughts of anger, but no intent or plan. He denied hearing voices. He continued to check the doors and locks. He reported a multi-year history of being bothered by loud noises and crowds. The Veteran continued to socially isolate himself. His family continued to be supportive. In a VA treatment note later that month, the Veteran reported issues with memory, impulse control, social isolation, and increased mood disturbance. He described trust and communication issues, but that he was working on them and was attending church again. In August 2011, the Veteran underwent additional VA examination with review of the claims file. The examiner noted the Veteran experienced the following symptoms: depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner noted the Veteran also experienced occupational and social impairment with reduced reliability and productivity. The examiner indicated that the Veteran worked for 16 years for a waste management company before retiring due to his feeling that he did not fit in there. The examiner noted that the Veteran was in counseling through VA and attended a support group there on a bi-weekly basis. As a result of this treatment, plus medication, there was some mild remission of his symptoms. However, the examiner concluded that the Veteran's PTSD symptoms caused clinically significant distress or impairment in social, occupational or other important areas of functioning. The examiner further opined that the Veteran's diagnosis of PTSD alone did not render him unable to secure or maintain employment noting that PTSD caused a reduced productivity efficiency and reliability in a work setting due to the Veteran's difficulty relating to co-workers and problems with anger and irritability. In an August 2011 treatment note, the clinician noted the Veteran was able to perform ADLs and had good hygiene. The Veteran reported continued problems with restless sleep and war-related nightmares which left him tired and irritable. He reported isolation from others in order to avoid conflict. At times, the Veteran neglected his own personal care by skipping meals and medications and neglecting his personal hygiene. He reported not making any new friends or making any effort to maintain old ones. At times, he was frustrated with his family and felt guilty about thinking so. The Veteran indicated some suicidal ideation, related to feelings of inadequacy in providing for his family, but had no plan. Notes from September, October and November 2011 all reflect a lack of suicidal or homicidal ideation. In a November 2011 VA treatment note, the Veteran indicated he continued to isolate himself from others in order avoid conflict. In January 2012, the Veteran indicated he was working on communication skills at church, working with his grandson to improve one-on-one communication and although he still had nightmares and flashbacks, he called some friends who were also veterans when felt the need to talk. He was noted to be dressed appropriately and assigned a GAF score of 48. In March 2012, the Veteran noted he continued to suffer mood swings, sleeping problems, issues with hyperarousal, trust and social isolation. No suicidal or homicidal ideation was noted. In a June 2012 treatment note, the Veteran was noted to be neatly dressed and groomed with good personal hygiene. His speech was normal and his affect constricted. The clinician noted the Veteran's mood was irritable and depressed. The Veteran reported continuous irritable mood to the point that his family avoided him and spends most of his time alone. He reported severe sleep disturbances with frequent awakenings and nightmares which occurred up to 3 times per week. The veteran denied suicidal or homicidal ideation. An October 2012 VA treatment note shows the Veteran exhibited severe psychiatric symptomology which interfered with his ability to function and maintain independence in the community. Later that month, the Veteran was seen by a VA clinician to evaluate his response to medication. He was noted to be alert and oriented, with intact memory and a regular speech rate. His affect was mildly flattened and his mood mildly depressed. He denied all suicidal or homicidal ideation, and there was no evidence of psychosis. In January 2013, the Veteran was seen at VA again for an evaluation of response to medication. He was alert and oriented, with an intact memory and normal speech. His thought processes were mildly constricted, his mood mildly depressed, and his affect subdued but appropriate. There was no evidence of psychosis and his insight and judgment were adequate. The Veteran reported sleeping only a few hours each night, in a recliner, and experiencing frequent nightmares. During the day he was active outside, and attended the veterans support group and talked to other veterans on the phone. The Veteran reported avoiding crowds and sitting in the back of his church during services. The clinician noted a history of poor sleep and nightmares, irritability, social isolation, watchfulness, easy startle, and distressing daytime memories. A May 2013 VA treatment note showed the Veteran continued to experience poor sleep and nightmares, irritability, social isolation, watchfulness, easy startle, frequent checking, and distressing daytime memories. The Veteran reported sleeping 3 to 4 hours per night, with nightmares 2 to 3 times a week. The clinician found the Veteran oriented times 4, with intact memory. His speech was at a regular rate and his thought process was constricted. He was noted to be mildly depressed and mildly irritable. The Veteran indicated that he continued to attend the support group for veterans. The Veteran denied suicidal or homicidal ideation, had adequate insight and judgment and exhibited no evidence of psychosis. In September 2013, the Veteran was seen at VA for an evaluation of his response to medication. At that time, the clinician noted much of the same symptoms as in his previous visit: poor sleep and nightmares, irritability, social isolation, watchfulness, easy startle, frequent checking, and distressing daytime memories. The Veteran indicated he relied on sleep medication, and it was noted that he slept for only a few hours a night. The Veteran noted continued participation in the veteran support group, and relayed that he called other veterans when needed. The clinician noted the Veteran to be oriented times 4, with an intact memory. His thought processes were constricted and he was noted to mildly depressed and mildly anxious. The Veteran denied any suicidal or homicidal ideation and his insight and judgment were noted as adequate. In December 2013, the Veteran underwent a VA PTSD examination. The VA psychologist noted that the Veteran was alert and oriented. His affect was mildly constricted and his mood was mildly depressed. The Veteran's speech was fluent and his mental status was within normal limits. The examiner found that the Veteran experienced a depressed mood, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. The examiner found that the Veteran's PTSD caused recurrent, involuntary and intrusive distressing memories, recurrent distressing dreams and that the Veteran avoided external reminders that aroused distressing memories, thoughts, or feelings. The Veteran was noted to have markedly diminished interest or participation in significant activities and feelings of detachment or estrangement from others. The Veteran displayed irritable behavior and angry outbursts with little or no provocation (typically expressed as verbal or physical aggression towards people or objects), hypervigilance, an exaggerated startle response, problems with concentration and sleep disturbances. The examiner concluded that these symptoms caused clinically significant distress or impairment in social, occupational or other areas of functioning. A January 2014 VA treatment note indicates the Veteran sought supportive counseling. He reported feeling down, irritable and morose around the holidays-feelings he had expected would abate once the holidays ended, but which had not. The Veteran indicated he was feeling more irritable and verbally agitated; he found that the veteran support group was extremely helpful. He indicated he felt close to his family. The clinician noted the Veteran was well groomed, with normal speech and a cooperative attitude. His mood was mildly depressed and affect mildly constricted. He denied experiencing any hallucinations and his thought process was linear and goal-oriented. The Veteran's thought content was appropriate and he denied any suicidal or homicidal ideation. The clinician noted the Veteran was oriented to person, place, time and situation, with both his long-term and short-term memory intact. The Veteran's concentration and attention were good, as was his impulse control, insight and judgment. The Veteran indicated experiencing a variable amount of sleep, adequate appetite and energy, with noted irritability and anger. The Veteran exhibited depressive and anxiety symptoms, mild in nature. No flashbacks were noted, although he did continue to experience nightmares on a weekly basis. In March 2014, the Veteran was seen at VA and noted he was feeling better, as his medication had been increased. The clinician found the Veteran was still experiencing poor sleep and nightmares, irritability, social isolation, watchfulness, easy startle, frequent checking, and distressing daytime memories. The Veteran indicated that he continued to attend the veterans support group, but otherwise avoided crowds. The Veteran was examined and found to be alert, oriented times 4, with an intact memory, regular speech and a subdued affect. His thought process was mildly constricted and his mood euthymic. There was no evidence of psychosis, and the Veteran denied all suicidal or homicidal ideation. The clinician found the Veteran's insight to be adequate. In a July 2014 VA treatment note, the Veteran reported feeling more aggravated than usual. The clinician noted the Veteran's sleep continued to be minimal, although the Veteran reported that some weeks he did not experience his usual intrusive nightmares. He continued to experience a startle response when someone walked up behind him, and reported sitting with his back against the wall when at church services. The Veteran continued to attend the veteran support group and talk to other veterans on the phone. When asked to describe how he felt in crowds, the Veteran indicated he became anxious, with avoidance, shortness of breath, a racing heart and sweaty palms. The clinician found the Veteran to be alert, with a serious demeanor, oriented times 4, with an intact memory and regular speech rate. The Veteran's thought processes were constructed and his mood euthymic, with a subdued and guarded affect. The Veteran denied all suicidal and homicidal ideation and exhibited no evidence of psychosis. The Veteran's insight and judgment were deemed adequate. Having considered all the evidence of record and the applicable law, the Board finds that a rating in excess of 70 percent for the Veteran's PTSD is not warranted. In this regard, as noted previously, 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 or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. In the instant case, the Board finds that the Veteran's PTSD symptomatology does not more nearly approximate total occupational and social impairment. In this regard, there is no evidence of gross impairment of thought processes or communication; in fact, the Veteran has been consistently able to actively communicate both in group and individual therapy. Similarly, the Veteran does not experience persistent delusions or hallucinations. The above records indicate the Veteran may have experienced a visual hallucination in March 2011, but this was attributed to his hypervigilance and, even if it were, such an isolated incident is not considered persistent. The whole of the record does not indicate that the Veteran displays grossly inappropriate behavior in any setting. The Board notes that the Veteran does appear demonstrates some symptoms which are examples supporting a 100 percent rating for PTSD. To that end, the Veteran reported an intermittent inability to perform activities of daily living, in that he must be prompted to bathe and take his medication by his wife. A VA clinician described the Veteran as having difficulty maintaining independence in his own community. However, this deficiency was only noted on a few occasions and is not reported as a persistent feature of his PTSD disability. Overall, the Veteran has been consistently noted by clinicians in the clinic setting to be well-groomed and cleanly dressed. Also, the Veteran's treatment notes document some incidents of memory loss; however, the only incident of such a loss that rises to the level of approximating the criteria for a 100 percent rating - the inability to remember details such as one's occupation, as reflected in the March 2011 VA examination - was discounted by the examiner as probable malingering. In any event, the memory deficit shown on the March 2011 VA examination is an isolated finding and there is no lay or medical evidence that such symptomatology has been frequent and/or recurrent. Here, the record indicates the Veteran has never had more than a rare incident of suicidal ideation or that he observes obsessional rituals of any kind. There is an incident of suicidal ideation in February 2010 and a reported past history of suicidal ideation, but the clinic records are replete with denials of suicidal ideation during the appellate period. The Veteran has never had legal trouble. The Veteran has withdrawn from social relations, but he does maintain social relations with family members and he calls other veterans from his support group to talk. Thus, the credible probative evidence demonstrates that there is less than total social isolation. Additionally, the Board notes that the Veteran was assigned GAF scores that, on average, were between 44 and 50. A score between 41 and 50 indicates 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 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). There is no question that the GAF score and interpretations of the score are important considerations in evaluating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter, supra. Here, the Veteran's GAF scores are reflective of serious impairment of employment which is addressed in the TDIU discussion below. However, these scores demonstrate some residual capacity to work and, thus, not total occupational impairment as contemplated in DC 9411. Therefore, the Board finds that, for the entire appeal period, the Veteran's PTSD has been manifested by significant occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking and mood due to such symptoms as near-continuous depression affecting the ability to function effectively, impaired impulse control (such as unprovoked irritability), neglect of personal appearance and hygiene, and difficulty in adapting to stressful circumstances. For example, VA treatment notes consistently note the Veteran's reports that he was unable to get along with co-workers and his irritability with his family members. The notes indicate a consistent depression. The December 2013 VA examiner indicated that the Veteran experiences impaired impulse control, manifested by unprovoked irritability. The Veteran was noted, as well, to experience difficulty in adapting to stressful situations. In addition, the record shows that the Veteran has some inability to establish and maintain effective relationships. Specifically, the Veteran reported that he decreased his socialization on multiple occasions, and that he isolated himself from his family. The Veteran also barred his grandchildren from visiting him at one point. However, the evidence also shows that the Veteran has maintained a 40-year marriage, regularly attends group therapy and goes to church. Later VA treatment notes indicate the Veteran was taking concrete steps to improve his communication skills both at church and in relation to a grandson. Consequently, despite the Veteran's contentions and taking into consideration his clinically significant distress and impairment, the weight of the evidence clearly indicates that a rating in excess of 70 percent for PTSD is not warranted. The Board has considered whether staged ratings are appropriate for the Veteran's service-connected PTSD. See Hart, supra. However, the Board find that his symptomatology has been stable throughout the appeal period; therefore, assigning staged ratings for such disability is not warranted. 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 Federal Circuit provided guidance in rating psychiatric disabilities, emphasizing that the list of symptoms under a given rating is non-exhaustive. Vazquez-Claudio, supra. The psychiatric symptoms present in this case are either listed in the schedular criteria or are similar in kind to those listed, as discussed above. Review of the record does not reveal that the Veteran suffers from any symptoms of PTSD that are not contemplated in the non-exhaustive list of symptoms found in the schedular criteria. Furthermore, the rating schedule provides for greater compensation for greater disability than that suffered by the Veteran. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. The Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, as the appeal does not involve evaluation of multiple service-connected disabilities, further discussion of Johnson is not necessary. 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). In sum, Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 70 percent for PTSD. Therefore, the benefit of the doubt doctrine is not applicable and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). B. TDIU The Veteran claims that his PTSD renders him unable to obtain and maintain substantially gainful employment. Total disability ratings for compensation may be assigned where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: Provided, that if there is only one such disability, this disability shall be ratable as 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16. For TDIU purposes, marginal employment is not to be considered substantially gainful employment. 38 C.F.R. § 4.17. Factors to be considered, however, will include the Veteran's employment history, educational attainment, and vocational experience. 38 C.F.R. § 4.16. Here, the Veteran's PTSD has been rated as 70 percent disabling for the entire appeal period. He is not service-connected for any other disability. Thus, the Veteran's 70 percent disability rating for PTSD meets the criteria for a schedular TDIU rating under 38 C.F.R. § 4.16(a) for the entire appeal period. In order to be granted a TDIU, the Veteran's service-connected PTSD, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In Moore v. Derwinski, 1 Vet. App. 356, 359 (1991), the U.S. Court of Veterans Appeals (now the U.S. Court of Appeals for Veterans Claims) (Court) discussed the meaning of "substantially gainful employment." In this context, it noted the following standard announced by the United States Federal Court of Appeals in Timmerman v. Weinberger, 510 F.2d 439, 442 (8th Cir. 1975): It is clear that the claimant need not be a total 'basket case' before the courts find that there is an inability to engage in substantial gainful activity. The question must be looked at in a practical manner, and mere theoretical ability to engage in substantial gainful employment is not a sufficient basis to deny benefits. The test is whether a particular job is realistically within the physical and mental capabilities of the claimant. The Veteran possesses a high school diploma and has not completed any college courses. He worked as a diesel mechanic for most of his career. He worked for Waste Management from December 1989 to March 2006 earning approximately $54,000 in his last year of work. He has not worked since. The Board first observes that the Veteran's 70 percent disability rating for PTSD, in and of itself, demonstrates limited residual ability to obtain and maintain substantially gainful employment. As discussed above, his GAF scores in the 40s range are indicative of serious impairment in social and occupational functioning to include an inability to hold a job. A VA examiner in December 2009 described the Veteran as demonstrating severe impairment of functioning due to symptoms of PTSD, including severe impairment of social functioning and severe impairment in occupational functioning. On the other hand, the Veteran's record also reflects some impressions against a finding of unemployability due to TDIU. A March 2011 VA examiner felt that the Veteran was malingering and a December 2011 VA examiner provided opinion that the Veteran's PTSD alone did not preclude his unemployability. Nonetheless, in a claim for TDIU, the ultimate question of whether a Veteran is capable of substantially gainful employment is not a medical one; that determination is for the adjudicator. See 38 C.F.R. § 4.16(a); see also Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). On review of the entirety of the record, the Board finds insufficient evidence of malingering on the part of the Veteran. His treating VA clinicians have described the Veteran's PTSD as being manifested by insomnia. The December 2009 VA examination was significant for findings of blunted affect, recall difficulty and poor motivation for completing ADLs. The Veteran's spouse has limited the Veteran's driving due to road rage and aggravation of his PTSD symptoms. A VA clinician in October 2012 described the Veteran as exhibiting severe psychiatric symptomatology which interfered with his ability to function and maintain independence in the community. As noted in Moore, the Board must address the TDIU question in a practical manner. Here, the record reflects that the Veteran possesses a high school degree and has primarily worked as a diesel mechanic. The medical examiners have described the Veteran's PTSD as resulting in severe occupational and social impairment which interferes with his ability to function and maintain independence in his community. Given his difficulty in maintaining his own independence, in the opinion of the Board, the Veteran does not practically maintain the ability to obtain and maintain substantially gainful employment consistent with his limited educational and vocational background. After considering the evidence for and against the claim, the Board finds the evidence at least equipoise as to whether the Veteran's service-connected PTSD has rendered him unemployable. As such, a reasonable doubt arises as to his employability, which must be resolved in favor of the Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert, supra. Therefore, the Board finds that the Veteran has been unable to secure and follow a substantially gainful occupation by reason of his service-connected PTSD for the entire appeal period. The claim, therefore, is granted. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. ORDER A rating in excess of 70 percent for PTSD is denied. TDIU is granted. ____________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs