Citation Nr: 1602377 Decision Date: 01/20/16 Archive Date: 01/27/16 DOCKET NO. 12-15 960 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating for acquired psychiatric disorder, including posttraumatic stress disorder (PTSD), in excess of 50 percent, effective from June 9, 1999, to September 27, 2009, and in excess of 70 percent since September 28, 2009. 2. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Bryan Held, Accredited Agent ATTORNEY FOR THE BOARD C. Fields, Counsel INTRODUCTION The Veteran served on active duty from December 1972 to April 1976. This matter initially came before the Board on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In a September 2009 rating decision, the RO implemented the Board's April 2009 decision to grant service connection for PTSD, and assigned a 50 percent initial rating, effective as of June 9, 1999. Later in September 2009, and in December 2009, the RO received statements from the Veteran and his representative, which were interpreted as new claims for an increased rating for the psychiatric disorder. The AOJ denied these "claims" in a December 2009 rating decision and an August 2010 rating decision, which also denied a TDIU, as pertinent to this appeal. The Veteran submitted a notice of disagreement in September 2010, a statement of the case (SOC) was provided in May 2012, and he submitted a substantive appeal (VA Form 9) for these issues in June 2012. The current appeal has previously been recognized as arising from the August 2010 decision denying an increased rating for PTSD. Because additional pertinent evidence regarding the severity of the Veteran's psychiatric disorder, to include a May 2010 VA examination, was received within the one-year appeal period after the September 2009 initial rating decision; and there was no determination as to whether the evidence was new and material, the September 2009 decision did not become final. See Beraud v. McDonald, 766 F.3d 1402 (Fed. Cir. 2014); Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011) (interpreting 38 C.F.R. § 3.156(b) (2015). Further, the Veteran's May 2010 application for a TDIU was based, in part, on his psychiatric disability; this is also pertinent evidence as to the rating for PTSD, as the applicable rating criteria specifically contemplated inability to sustain employment. In November 2014, the Board granted an initial 70 percent rating for the Veteran's psychiatric disorder, and deferred consideration of the question of whether a rating in excess of 70 percent was warranted. This question was deferred and remanded, pending the completion of further directed development, to include as to an intertwined claim to reopen for service connection for alcoholism, which the Board stated was raised by the Veteran's reports in a May 2010 VA examination. The issue of "whether new and material evidence had been submitted to reopen a claim for service connection for alcoholism, as secondary to the service-connected psychiatric disorder" was listed as an issue on the front page of the Board's November 2014 decision. The Board; however noted that this issue had not been decided by an agency of original jurisdiction (AOJ), and it was remanded for such adjudication on the basis that it was inextricably intertwined with the PTSD and TDIU issues on appeal. The AOJ did not issue a rating dación on alcoholism issue; but adjudicated it in the July 2015 supplemental statement of the case (SSOC). The AOJ reopened the claim, but denied service connection for alcoholism on the merits. This document constitutes the required first adjudication of this claim since the previous denial, in lieu of a separate rating decision; however, the Veteran was not provided his appellate rights. See Ingram v. Nicholson, 21 Vet. App. 232, 241 (2007) (holding that the time period to appeal a VA decision does not commence, and the decision will not become final, if the appellant is not notified of the decision and the appellate rights). The Board lacks jurisdiction over this issue because a notice of disagreement has not been received. 38 U.S.C.A. § 7105(a) (West 2014). Although the AOJ certified this issue to the Board via a VA Form 8, this is used for administrative purposes and neither confers nor deprives the Board of jurisdiction over appeals. 38 C.F.R. § 19.35 (2015); cf, Percy v. Shinseki, 23 Vet. App. 37, 47 (2009) (holding that VA actions, including certification of an issue to the Board may waive the filing of a timely substantive appeal). FINDINGS OF FACT 1. Since June 9, 1999, the Veteran's service-connected psychiatric disorder has resulted in occupational and social impairment with deficiencies in most areas due to symptoms of severity, frequency, and duration most nearly approximating the 70 percent rating criteria; but not total occupational and social impairment. 2. In light of the rating award herein, the Veteran has a 70 percent rating for service-connected psychiatric disorder throughout the appeal period, and he has been unable to maintain substantially gainful employment due to such disability. CONCLUSIONS OF LAW 1. Since June 9, 1999, the criteria for an initial rating of 70 percent for the service-connected psychiatric disorder have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Codes 9411, 9499-9413 (2015). 2. The criteria for a rating in excess of 70 percent for the service-connected psychiatric disorder have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Codes 9411, 9499-9413. 3. The criteria for entitlement to a TDIU since the effective date of service connection for psychiatric disorder have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Board's decision herein is a complete grant of the benefit sought for the TDIU issue. The other issue on appeal arises from the rating assigned following the grant of service connection for the Veteran's psychiatric disorder. No further notice is required under the Veterans Claims Assistance Act (VCAA) regarding the downstream issue of a higher initial rating, and no prejudice has been alleged. 38 U.S.C.A. § 5103(a); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Moreover, the Veteran was notified of the requirements to establish an increased rating for his psychiatric disorder, including the effective date, in November 2009. Additionally, the AOJ obtained all identified and available medical records, including updated VA records as directed in the prior remand, as well as records from the Social Security Administration (SSA) that were received in 1999. The AOJ notified the Veteran in August 2010 that records of identified treatment at the Durham VA Medical Center (VAMC) were unavailable for the period from January 1993 through April 2010, based on an August 2010 negative response from that facility. The Veteran was allowed an opportunity to provide any such records. Further, records of treatment at several VA facilities were obtained from 1997 through July 2015; and the SSA records include lay and medical information from 1993 to 2000. Private records were also obtained for non-mental health conditions. The Veteran was afforded several VA examinations for his psychiatric disability, most recently in April 2015. This examiner identified the currently diagnosed psychiatric disorders, and indicated that there were no new disorders, as directed by the prior remand in response to a statement in the May 2010 VA examination report. There is no argument or indication that any pertinent records remain outstanding, or that the VA examination is inadequate or inaccurate. In sum, there is no additional notice or assistance that would be reasonably likely to aid in substantiating the aspect of the claim that is decided herein. VA has satisfied its duties to inform and assist. II. Analysis VA's percentage ratings are based on average impairment of earning capacity from service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, 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 reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Evaluation of a mental disorder requires consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the capacity for adjustment during periods of remission. Evaluations will be assigned based on all evidence that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of the examination. The extent of social impairment shall also be considered, but an evaluation may not be assigned based solely on the basis of social impairment. 38 C.F.R. § 4.126. Percentage ratings for service-connected mental health disabilities are based on the criteria in the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list but, rather, serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating for a mental disorder. In addition to the symptoms listed in the rating schedule, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The DSM-IV provides for a global assessment of functioning (GAF), a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DSM-IV). A veteran may only qualify for a given disability rating "by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Although a veteran's symptomatology is the primary consideration in determining the appropriate disability rating based on a mental health disorder, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in "most areas" with regard to the 70 percent rating. Id. The criteria for a 50 percent rating are: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, DC 9411 and 9499-9413. The criteria for a 70 percent rating are: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. The criteria for a 100 percent rating are: 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. Id. The Veteran's psychiatric disability is currently rated as 50 percent disabling prior to September 28, 2009, and 70 percent disabling from that date forward. As discussed below, a 70 percent rating is warranted for the entire appeal period. As noted in the prior Board decision in November 2014, the May 2010 VA examiner suggested that the Veteran had deterioration in his mental status since the last VA examination in 2008 due to either his ongoing alcohol dependence or to a new, unspecified psychiatric diagnosis, not due to his service-connected disorder. The Board remanded the issue of whether a rating higher than 70 percent was warranted, to include whether there was another psychiatric diagnosis, and whether alcoholism was secondary to the Veteran's service-connected psychiatric disorder. As explained in the introduction section above, the issue of separate service connection for alcoholism, is not under the Board's jurisdiction at this time because there was no notice of disagreement after the initial adjudication of the claim to reopen this matter by the AOJ in July 2015. Nevertheless, the evidence shows that the mental health effects of the Veteran's alcohol abuse cannot be differentiated from his service-connected psychiatric disorder. The benefit-of-the-doubt doctrine requires all signs and symptoms to be attributed to the service-connected condition where it is not possible to separate the effects of the service-connected and nonservice-connected conditions. Mittleider v. West, 11 Vet. App. 181, 182 (1998). The April 2015 VA examiner concluded that although the Veteran had intermittently been diagnosed with depression or related conditions, with references to personality disorder, all of his clinical symptoms were best explained by a combination of trauma-related disorder (which is service-connected) and ongoing substance use. Further, consistent with the May 2010 examiner's statement that alcohol abuse had exacerbated the Veteran's service-connected mental health disability, the April 2015 examiner stated the Veteran's mental health disorders were mutually aggravating. The April 2015 VA examiner concluded that he could not differentiate the symptoms of each disorder without resorting to mere speculation. Although the May 2010 examiner assigned a different GAF score when considering the effects of the alcohol abuse disorder and possible mixed personality traits, in addition to the service-connected anxiety disorder with PTSD; that examiner did not specify the symptoms that were due to alcohol abuse or other diagnosis. Therefore, although it is not currently service-connected, the effects of the Veteran's alcoholism or alcohol abuse will be considered in determining the appropriate rating for his service-connected psychiatric disability. Id. Throughout the appeal period, although the Veteran abstained from substance abuse at times, he reported heavy alcohol and other substance abuse for the majority of the time, and he had several periods of inpatient treatment for detoxification (detox). The Veteran sought treatment and took psychiatric medications at times, which helped his symptoms to some extent, but he had did not appear for several appointments and had no regular mental health treatment or medications for extended periods, including since 2008. He has had fluctuating symptoms and impairment, and at times, depression and PTSD screens were negative. See, e.g., VA treatment records in September 2009, December 2012, and July 2015. Nevertheless, throughout the appeal period, the Veteran has frequently reported depressed mood, feelings of hopelessness and worthlessness, decreased energy and appetite, anhedonia or loss of interest in prior activities, and crying spells. He has also had frequent anger, irritability, possible panic attacks, anxiety, nervousness, agitation, frustration when interacting with people, and felt tense or stressed. The Veteran reported avoiding thoughts or reminders of military and other past traumas, but still had unwanted memories, intrusive thoughts, flashbacks and exaggerated startle response associated with unexpected loud sounds. He also had sleep impairment with nightmares, which woke him up at times and sometimes resulted in him yelling and striking out at night. There were a few notations that he avoided eye contact, had decreased psychomotor activity, constricted or blunted affect, and weight loss. See, e.g., VA treatment records from March to December 1999, March 2000, October 2007, July 2008, August 2008, October 2010, September 2013, and July 2014; VA examinations in May 2008, May 2010, and April 2015. The Veteran also reported suicidal ideation several times, which is contemplated by the 70 percent rating, as well as occasional thoughts of harming others or homicidal ideation. See, e.g., VA treatment records in March 1999, April 1999, December 1999, May 2000, October 2007, July 2008, August 2008, and October 2010; VA examination in May 2008, May 2010, and April 2015. Nevertheless, the Veteran repeatedly denied any plan, intent, or actual attempts at suicide or harming himself during the appeal period. The May 2008 examiner summarized that he had chronic, intermittent suicidal ideation without plan or intent. The Veteran also repeatedly denied homicidal intent, and although he reported having trouble controlling violent behavior in December 1999, he consistently denied any violent episodes. As such, the evidence does not show a persistent danger of the Veteran hurting himself or others. The Veteran's speech was occasionally noted to have some abnormalities, such as being monotone, slow or quick, soft-spoken, mumbled, halting and with sighs, with a stutter or notable accent, slurred, pressured. At other times, however, his speech was noted to be clear or with no abnormalities. Although the April 2015 examiner noted that the Veteran's speech was poorly articulated, there was no evidence to suggest that any speech difficulties resulted in gross impairment of communication. Further, the majority of records indicated that the Veteran's thought processes were not grossly impaired. Treatment records in March and April 1999 noted that his thought processes were goal directed, with no abnormal content, intact reality testing, and fair attention and concentration. In December 1999, the Veteran reported some trouble understanding and concentrating. Records in October 2007 noted that the Veteran had trouble concentrating, and that his thought form was tangential, but had no other abnormalities. In August 2008 a provider recorded that there were no abnormalities of thought process, although the Veteran had concentration problems. In a March 2009 private record, the Veteran was noted to have clear and coherent speech. The April 2015 examiner stated that the Veteran had abstract reasoning, and his thought processes were logical and organized. The Board notes that the May 2010 VA examiner stated that the Veteran had grossly impaired cognitive ability; however, no explanation was provided for this statement. The May 2008 examiner stated that the Veteran appeared to be an unreliable historian with possible cognitive defects, and that he had definite difficulty with both recent and remote memory. This examiner also noted the Veteran's reports of difficulty concentrating. Similarly, the May 2010 examiner appears to have been referring to the Veteran's lack of judgment and insight and memory difficulties in stating that there was gross cognitive impairment. These do not arise to gross impairment of thought processes, as contemplated by a 100 percent rating. Instead, memory, judgment, and thinking are separated out as different qualities to be assessed for determining severity. Further, records near the time of the 2010 examination, as well as before and after, indicate that the Veteran continued to function in many ways that require functioning thought processes. As such, the May 2010 examiner's statement in this regard is not consistent with the examiner's other statements, or with the other records, and it is rejected. With regard to memory, the Veteran has reported difficulty remembering past names and details, as well as needing to write things down to remember them. See, e.g., VA treatment records in July 1999, August 2008. As noted above, the May 2008 examiner stated that he had difficulty with recent and remote memory. The May 2010 examiner stated that the Veteran was a very poor historian, in that he could not remember dates, times, or places of his military service or other matters. The April 2015 examiner also stated that the Veteran was a notably poor informant. There is no indication, however, of memory loss for names of close relatives, the Veteran's own name or prior occupations, or his own name. Rather, the nature and severity of his memory difficulties are contemplated by the 70 percent rating. The evidence does not establish grossly inappropriate behavior at any point. A September 2002 private record noted that the Veteran and his nephew were being loud and cursing. Although this was noted to be inconsiderate to neighboring patients, it was not grossly inappropriate. In June 2013, a behavioral flag was placed on the Veteran's file at the VAMC due to him using disrespectful language and having threatening behavior toward staff, noting that he was belligerent when intoxicated. A September 2013 record noted that the Veteran would get angry when discussing his medical issues, and that he had a behavioral flag on his file. Thus, although the episode resulting in a behavioral flag was inappropriate and lack of impulse control, it was not grossly inappropriate. Otherwise, the Veteran was otherwise been noted to be cooperative, responsive, and to have appropriate behavior. See, e.g., treatment records in March 1999, April 1999, September 2006, October 2007, August 2008, January 2012. He also consistently denied any legal problems or arrests during the course of the appeal. There is also no evidence of disorientation to time or place, as the Veteran was consistently noted to be fully oriented in all spheres for treatment and examination. The Veteran has consistently denied delusions, but he reported having auditory and visual hallucinations at times. He described these hallucinations as hearing someone calling his name, hearing a "devil's voice" occasionally since service, thinking a nurse had entered his room during detox treatment, occasionally seeing shadows flash by and thinking a person is there, or hearing people talking in the background even if no one is around him. See, e.g., treatment records in April 1999, December 1999, October 2007, and October 2010. The May 2008 examiner recorded that the Veteran denied any overt auditory or visual hallucinations, but he reported seeing things he could not explain at times, and occasionally hearing a voice or his name being called. The May 2010 examiner stated that the Veteran appeared confused, quite distracted, and at times preoccupied possibly by internal stimuli, and certainly with other wants such as food and transportation. Treatment records in January 2012, however, noted no active hallucinations; and the April 2015 examiner recorded that there were no reported or observable perceptual disturbances. Although this symptom is listed in the 100 percent rating criteria, there is no indication that the Veteran's occasional hallucinations significantly affected his general social interactions or resulted in total social impairment. There have been some notations of neglect of personal appearance and hygiene, as contemplated by the 70 percent rating. A March 1999 record stated that the Veteran was poorly groomed. At the April 2015 VA examination, the Veteran reported that he took "a little bird bath" intermittently, but he denied a regular schedule of bathing or showering. The evidence does not, however, rise to the level of intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). Although treatment records in September 2006 and July 2014 treatment stated that the Veteran appeared to have poor activities of daily living skills and that his mother helped with most activities of daily living, respectively, the problems listed were mainly due to blindness. Multiple records noted that the Veteran did work and chores around the house, ran errands, groomed, dressed, bathed, cooked meals and fed himself regularly, and was able to monitor and manage his own medications. See treatment records in August 2000, January 2012, September 2013, October 2013, August 2014; VA examination in May 2010. Despite describing some neglect of personal hygiene in April 2015, the Veteran presented with fair hygiene and grooming, dressed casually, and he reported eating three meals a day, completing chores around the house, and running errands. The Veteran was homeless and lived at a shelter at times prior to the appeal period, and as noted in treatment records from July 2003 to October 2003. A September 2006 record noted that the Veteran was "homeless" and had previously lived in a shelter, but stated that he was currently living with his mother. Subsequent records noted that he continued to live with his mother or other family members. Despite these notations of homelessness, the Veteran continued to function effectively in general. An August 2003 social work record noted that the Veteran was arranging for a ride to retrieve his belongings from the shelter, he was casually dressed, fully oriented, had no suicidal or homicidal ideations, and no hallucinations. Thus, this period of homelessness does not rise to the level of severity of the types of symptoms contemplated by a 100 percent rating, or show total impairment. Although the Veteran has had difficulty with personal relationships, he has not had total social impairment. He lived with his mother and other family members in March 1999, with other people in a halfway house in May 1999 and July 1999, and with friends from September 1999 through August 2000. He also participated adequately in group therapy sessions and detox treatment in 1999. Although the Veteran was separated from his current wife since 1989, and he has reported feeling numb, detached, and unable to experience love and happiness at times, he reported having a girlfriend who would stay overnight at times in August 2000. The Veteran has also repeatedly shown caring and commitment to his elderly mother throughout the appeal period. See, e.g., records in March 1999 (he wanted to remain sober to be able to help her), October 2007 (he would get angry at how his siblings treated her), August 2008 (he would regroup from thoughts of suicide by thinking about responsibilities in caring for his mother); January 2012 (he lived with and took care of his mother as needed, with minimal social support). Further, the Veteran had a positive relationship with other family members at times. A September 2002 private record noted that his nephew accompanied him to the emergency room for a physical ailment and they were laughing and talking together. In October 2007, the Veteran stated that many people count on him for help. The Veteran described a cooperative relationship with two of his sisters in September 2008, stating that they could not help him with transportation due to their difficulties with driving at night. The Veteran's brother and niece again lived with him and his mother at times in January 2012, and the Veteran continued living with his adult niece and nephew after November 2014, when his brother moved back into the area and took their mother to live with him. An April 2015 VA treatment record noted that the Veteran again lived with his mother and cared for her without help, and he did not want to move her to a care facility. The Veteran reported wanting to be alone, and having social withdrawal and few or no friends or social activities at times. In addition to family interactions, however, he reported in April 1999 that he would usually drink with other people, and he went to church and outside meetings for substance abuse therapy from June 1999 to November 1999. He also denied any serious conflicts with family or friends during the past month in November 1999, and he lived with friends at that time. In an August 2000 for his continuing SSA benefits, the Veteran reported having social contacts every once in a while, and that he would walk daily, ride the bus, and would read and fish for leisure. In July 2008 and August 2008, the Veteran again indicated that he would walk around in public. A January 2012 record noted that the Veteran appeared to have no social issues or needs except for ongoing transportation issues. In October 2013, the Veteran reported using city buses, walking in his yard and in public places, reading, watching television, playing card games, and walking to the store. He also attended social and family events such as parties, entertained in his home, went out to eat, and shopped for groceries. In August 2014, he continued to use the bus for appointments and travel to the grocery store. In April 2015, the Veteran reported that he would say "hi" to people at the store. He also interacted with his cousin frequently, such as drinking, going to the store or park, fishing, and discussing his current situation and "feeling better." . The Veteran has been assigned GAF scores ranging from 30 to 60 since shortly before the appeal period. See treatment records in March 1999 (score of 30 on admission and 60 on discharge), April 1999 (score of 45), July 1999 (score of 35), October 2007 (score of 35 on admission and 55 on discharge), May 2008 (score of 40), May 2010 (score of 30 when considering all psychological impairment). Similarly, the May 2010 examiner summarized that the Veteran had major impairment in social adjustment and was at least as likely as not totally unemployable due to his mental health impairment. The April 2015 VA examiner did not assign a GAF score, but stated that the Veteran's psychiatric disability resulted in notable functional impairments, but that depending on the severity of his substance use at the time, he was reasonably capable of completing tasks of daily living, and he also had some meaningful interpersonal relationships. A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations; or there is serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation); or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A GAF score of 31 to 40 indicates that the examinee has 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., avoids friends, neglects family, and is unable to work). A GAF score of 41 to 50 indicates that the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates the presence of moderate symptoms (e.g., flat affect, circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). Neither a GAF score nor an examiner's summary is determinative of a Veteran's level of impairment due to mental health symptomatology; such evidence must be considered together with all evidence of record. As discussed above, the Veteran has had periods of occasional hallucinations, suicidal preoccupation, continuous unemployment with the exception of temporary jobs, a short period of homelessness, and varying degrees of interaction with friends and the public, in addition to other symptoms and impairment. He clearly has had major impairment in most areas of life, consistent with the repeated assignment of GAF scores in the 31 to 50 range. The GAF scores of 30 were assigned in March 1999, prior to the effective date of service connection, and upon inpatient admission due to suicidal preoccupation, which resolved during that treatment episode; and by the May 2010 examiner. The symptoms shown by the Veteran's reports during the 2010 VA examination, as well as at other times during the appeal, do not show that he is unable to function in all areas, or that he has total social and occupational impairment. In sum, the Veteran has not worked gainfully since the 1990s, and he has had varying levels of impairment due to psychiatric symptoms. Resolving reasonable doubt in his favor, although there have been some periods of increased and decreased function, these episodes were not so distinct as to warrant a different level of disability rating. The Veteran's symptoms have resulted in deficiencies in most areas of life; and his symptoms and overall impairment have most closely approximated the 70 percent disability level since the effective date of service connection, June 9, 1999. Thus, staged ratings are not appropriate. See Fenderson v. Brown, 12 Vet. App. 119, 126-27 (1999). Further, as discussed below, the evidence warrants a TDIU based on occupational impairment for the entire appeal period. The Veteran's symptoms have not, however, resulted in both total social and occupational impairment, as he has maintained social interactions. Thus, the nature, severity, and frequency of symptoms and overall level of impairment due to psychiatric disability have most nearly approximated the 70 percent rating criteria. 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411; see also Vazquez-Claudio, 713 F.3d at 117. There is no argument or indication that extra-schedular consideration is warranted under 38 C.F.R. § 3.321(b)(1). As detailed above, the Veteran has had social and occupational impairment as a result of her PTSD symptoms, and the mental health rating criteria are intentionally broad to account for all mental health symptoms and levels of impairment. His symptomatology is fully contemplated by the schedular rating criteria. Therefore, the rating schedule is adequate, and it is not an exceptional or unusual disability picture; referral for consideration of an extra-schedular rating is not necessary. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Further, PTSD is the only service connected disability; hence an extraschedular combined effects rating is not for consideration. Cf. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). A rating of 70 percent has been granted for the entire appeal period based, in part, on the resolution of doubt in the Veteran's favor. The preponderance of the evidence is against a higher rating; therefore, reasonable doubt does not arise, and the benefit-of-the-doubt doctrine does not apply in this respect. 38 C.F.R. § 4.3. TDIU A TDIU may be assigned where the schedular rating is less than total if it is found that the claimant is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Generally, a rating percentage threshold must be met: if there is a single service-connected disability, as in this case, it must be ratable at 60 percent or more. 38 C.F.R. § 4.16(a). In light of the rating award herein, the Veteran has a 70 percent rating for his service-connected psychiatric disorder, effective since June 9, 1999. Thus, he meets this rating threshold. Id. In determining unemployability for VA purposes, consideration should be given to the veteran's level of education, special training, and previous work experience. 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Faust v. West, 13 Vet. App. 342 (2000). A veteran need not show 100 percent unemployability in order to be entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. The Veteran applied for a TDIU in May 2010, stating that he had been unable to work full-time since the 1990s due to his service-connected psychiatric disorder and glaucoma. He is only service-connected for the psychiatric disorder. VA treatment records show treatment for psychiatric symptoms, as well as for nonservice-connected disabilities of glaucoma with legal blindness, history of cancer of the tongue with partial glossectomy, esophageal stricture, pain disorder, gastroenteritis, pancreatitis, hypertension, back pain, and substance abuse. There is evidence that the Veteran's non-psychiatric conditions contributed to his inability to work; indeed, his SSA disability benefits were awarded effective in 1991 based primarily on physical disabilities. There are also opinions, however, that the effects of his psychiatric disorder alone, when considering the effects of alcohol abuse, would preclude gainful employment throughout the appeal period. As noted above, VA examiners opined that the effects of the Veteran's alcohol abuse cannot be distinguished from his other mental health symptoms; therefore, such effects must be considered in determining his employability. In October 1993 report for an examination in connection with a claim for SSA benefits. The Veteran reported a work history of mostly unskilled labor jobs and some semi-skilled jobs, with employment lasting for months or years at a time, and the last employment as a construction worker. The Veteran stated that he had lost several jobs due to alcoholism. He further reported having a high school equivalency degree (GED) and one semester of college. As discussed above, the Veteran has had a similar level of impairment due to psychiatric disability throughout the appeal period, which began in June 1999. Although the Veteran reported having some temporary jobs in 1999 and 2000, there is no indication that they constituted substantially gainful employment. In a July 1999 VA PTSD evaluation for treatment, the provider stated that the Veteran's psychiatric symptoms had caused total occupational impairment. The May 2010 VA examiner noted that the Veteran had numerous physical problems that may have added to his problems working, but also stated that the Veteran would be unable to perform the tasks required of most full-time positions due to cognitive and emotional difficulties as a result of his mental health dysfunction. He stated that the symptoms of anxiety disorder, along with alcohol dependence, would make it at least as likely as not that he would be unemployable. The April 2015 VA examiner concluded that there was no way to reliably determine the impact of the Veteran's current PTSD symptoms on his overall functioning in the absence of nonservice-connected disabilities. The examiner stated that a clinical opinion regarding employability would be pure speculation. Resolving doubt in the Veteran's favor, the effects of his psychiatric disorder alone, to include the effects of alcoholism that cannot be distinguished, have rendered him unemployable for VA purposes throughout the appeal period. As he also meets the schedular percentage threshold, a schedular TDIU is warranted. 38 C.F.R. § 4.16. ORDER An initial rating of 70 percent for service-connected psychiatric disorder, to include PTSD, effective June 9, 1999, is granted. An initial rating in excess of 70 percent for PTSD, is denied. A TDIU is granted, effective June 9, 1999. ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs