Citation Nr: 1603235 Decision Date: 02/01/16 Archive Date: 02/11/16 DOCKET NO. 09-43 327 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period beginning October 19, 2010. 2. Entitlement to a total disability rating based on unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Jan Dils, Attorney at Law ATTORNEY FOR THE BOARD C. Fleming, Counsel INTRODUCTION The Veteran had active military service from March 1966 to March 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In an October 2007 rating decision, the RO granted service connection for PTSD, assigning an initial 10 percent disability rating. In March 2008, the RO granted an increased rating of 50 percent for PTSD, effective from December 14, 2007. The Veteran timely appealed the decision, and the Board issue a decision in April 2014 in which it granted an initial 50 percent rating to October 18, 2010, and remanded the issue of a rating in excess of 50 percent from October 19, 2010, for further evidentiary development and adjudication. In that remand, the Board instructed the agency of original jurisdiction (AOJ) to provide VCAA-compliant notice, obtain additional VA treatment records, and then re-adjudicate the claims. The AOJ sent the Veteran VCAA notice in May 2015, obtained the identified VA records, and provided the Veteran a supplemental statement of the case (SSOC) in October 2015. Thus, there has been compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). FINDINGS OF FACT 1. For the entirety of the period beginning October 19, 2010, the Veteran's PTSD has been manifested by disturbances of motivation and mood, difficulty in crowds, feelings of stress and hypervigilance, and difficulty in adapting to stressful circumstances that approximate occupational and social impairment with reduced reliability and productivity. 2. Service connection is in effect for PTSD, rated as 50 percent disabling; PTSD is the Veteran's only service-connected disability. 3. The most probative evidence reflects that the Veteran does not meet the schedular criteria for TDIU and is not precluded from participating in substantially gainful employment due to his service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for the Veteran's PTSD have not been met for the period beginning October 19, 2010. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.130, Diagnostic Code 9411 (2015). 2. The criteria for a total disability rating due to individual unemployability as a result of service-connected disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16, 4.19 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The United States Court of Appeals for Veteran Claims' (Court's) decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically 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 a claim for VA benefits. In January 2008, October 2008, and May 2015, the Veteran was issued VCAA notice pertaining to his claims. The letters notified the Veteran of what information and evidence is needed to substantiate his claim, as well as what information and evidence must be submitted by the claimant, what information and evidence will be obtained by VA, and the types of evidence necessary to establish a disability rating and effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); but see VA O.G.C. Prec. Op. No. 1-2004 (Feb. 24, 2004). The contents of this notice fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of any notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Board also finds that VA has complied with all assistance provisions of VCAA. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The evidence of record contains the lay statements of the Veteran, as well as records of his ongoing post-service treatment from VA and private treatment providers. The evidence of record contains reports of examinations requested by VA performed in December 2006, February 2008, January 2009, and July 2015. Such examination reports, when taken together, are thorough and contain sufficient information to adjudicate the issues on appeal. McLendon v. Nicholson, 20 Vet. App. 79 (2006). For all the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issues on appeal. Criteria & Analysis Claim for Increase The Veteran contends that his PTSD is more disabling than reflected by the 50 percent disability rating assigned from October 19, 2010. Relevant evidence of record consists of VA examination conducted in July 2015, as well as records of ongoing treatment the Veteran has obtained from VA and private treatment providers. Records of VA treatment reflect that the Veteran has received ongoing care for his PTSD, including consistent reports of discomfort when in crowds, difficulty with motivation, feelings of helplessness, and problems with sleep, including nightmares. At mental health visits in 2011, the Veteran repeatedly complained of struggling when in crowds, preferring to stay at home, and stated that he experienced ongoing feelings of helplessness. He reported that he continued to maintain a good relationship "the majority of the time" with his wife. At each such treatment visit, he was noted to display no psychosis or suicidal or homicidal ideation, and his mental status was consistently assessed as normal. He underwent a suicide assessment in June 2011; at that time, he initially reported some homicidal ideation but then retracted the statement, reporting instead that he was "easily agitated" with others but was able to manage his emotions. He was assessed at that time as a low risk for suicidal or homicidal ideation. Later treatment records reflect that the Veteran complained in October 2012 of some past fleeting suicidal ideation but denied any suicidal or homicidal ideation at the time. At that time, he reported being hypervigilant and guarded, particularly in crowds, and stated that his mood was "kinda stressful." His mental status was again assessed as normal, and he was assigned a GAF score of 60. In addition, the Veteran is an ongoing participant in a Veterans' PTSD group; records of meetings from throughout the appeal period reflect that he has consistently been noted as being attentive and engaged, with a euthymic mood. The Veteran underwent VA examination in July 2015. Report of that examination reflects that he reported having retired in 2003 from a job he had held for 27 years. He stated that he remained married to his wife of 45 years, although he said he was sometimes annoyed by her making decisions without consulting him. He also reported good relationships with his adult children and his grandchildren, whom he stated he saw once or twice a week. He stated that he had one friend outside his family whom he saw multiple times per month and also reported that he took an annual week-long fishing trip with several friends. He stated that he attended church every week and went out to eat about once per month. He also reported helping with household chores, including grocery shopping, but stated that he got irritated easily while driving. He complained of daily intrusive memories and nightmares occurring three to five times per month. The examiner noted the Veteran's report of feeling responsible for the death of a friend in Vietnam, as well as his avoidance of thoughts and memories of his time in service and his decreased interest in activities. He also reported feeling hypervigilant, forgetful, and distant from others, but denied panic attacks or angry outbursts. The examiner noted symptoms of anxiety, suspiciousness, chronic sleep impairment, memory impairment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances. The Veteran's grooming and hygiene were good, with good eye contact and cooperation and no abnormalities of mental status. The examiner diagnosed the Veteran with PTSD and found him to have occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, finding his symptoms to be mild or moderate in severity. Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, and VA must address the evidence concerning the state of the disability from the time period one year before the claim for an increase was filed until VA makes a final decision on the claim. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's PTSD has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). Under the General Rating Formula For Mental Disorders, to include PTSD, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. 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); inability to establish and maintain effective relationships. Id. 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); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. 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 a veteran working or seeking work. 38 C.F.R. § 4.2 (2015). The level of occupational and social impairment due to a psychiatric disorder is the primary consideration in determining the severity of a psychiatric disorder for VA purposes, and not all the symptoms listed in the rating criteria must be present in order for a rating to be warranted. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002) (finding that symptoms contained in rating schedule criteria are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating"). Upon review of the relevant medical evidence, the Board finds that the Veteran's PTSD has been consistent with the criteria for a 50 percent rating throughout the appellate period in question, and that a higher rating is thus not warranted. In that connection, the Board notes that the Veteran has been treated on multiple occasions for complaints of problems with motivation and difficulty in crowds, as well as feelings of helplessness, stress, and hypervigilance. He was specifically noted at his July 2015 VA examination to display occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Hence, the Board finds that the Veteran's PTSD more nearly approximates the assigned 50 percent rating for occupational and social impairment with reduced reliability and productivity, as manifested by the Veteran's difficulty with motivation, feelings of helplessness, irritability, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (holding that symptoms recited in the rating schedule for mental disorders are to serve as examples of the type and degree of the symptoms and not an exhaustive list). In so concluding, the Board finds particularly persuasive the Veteran's ongoing complaints of problems with motivation, feelings of helplessness, hypervigilance, and difficulty in adapting to stressful circumstances, as well as mildly impaired memory and disturbances of motivation and mood. The Board notes, as discussed above, that it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21 (2015). Nonetheless, upon review of the relevant medical evidence discussed above, the Board finds that the Veteran's PTSD has been manifested by symptoms resulting in occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective relationships. See 38 U.S.C.A. § 5017(b); 38 C.F.R. §§ 3.102, 4.3, 4.130 (Diagnostic Code 9411). The evidence indicates that the Veteran has consistently experienced this level of symptomatology from October 19, 2010. Therefore, a rating in excess of the 50 percent disability rating assigned from October 19, 2010, is not warranted for the entirety of the appellate period. In that connection, the Board notes that there is no evidence that the Veteran has problems tantamount to obsessive or ritualistic behavior that has interfered with his routine activities. There is, further, no evidence that he has at any time displayed stereotyped speech, difficulty in understanding complex commands, impaired judgment, or impaired abstract thinking. To the contrary, the Veteran has regularly denied suicidal and homicidal ideations and psychotic symptoms. He has further consistently reported to his VA treatment providers that he is not experiencing visual or auditory hallucinations. In addition, at no time has any treatment provider or examiner noted the Veteran to have illogical, obscure, or irrelevant speech, as identified in the General Rating Formula for Mental Disorders. These are the sort of things that strongly suggest that he does not experience deficiencies in most area as is required for a 70 percent rating. Rather, his difficulties are akin to the problems identified by the criteria for a 50 percent rating, with reduced reliability and productivity as a result. In particular, the Board notes that during the entirety of the appellate period, the Veteran has not been found to have deficiencies in most areas-work, school, family relations, judgment, thinking, and mood. Thus, the Board finds that a higher rating is not warranted. In reaching its conclusion, the Board finds particularly persuasive the Veteran's ongoing mood disturbances, irritability, problems with crowds and concentration, and hypervigilance, as recorded on multiple occasions and discussed above. The Board also acknowledges findings of the July 2015 VA examiner that the Veteran's symptomatology is "mild" to " moderate." The Board notes, however, that words such as "moderate," "marked," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "contemplated by the requirements of the law." 38 C.F.R. § 4.6 (2015). Use of terminology such as "moderate" or "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2015). As such, the Board finds that the initially assigned rating of 50 percent for the Veteran's service-connected PTSD for the period beginning October 19, 2010, is proper. In addition, the Board finds that the Veteran at no time has experienced near-continuous panic or depression and has not been so irritable as to have periods of violence. The Board acknowledges that there is some evidence of occupational and social impairment. In addition, the Veteran has reported that he does not often socialize outside his immediate family. Nevertheless, he has stated that he enjoys spending time with his family, as well as with a friend whom he sees weekly, and that he continues to attend church every week and goes on a week-long fishing trip every year with a group of friends. As discussed above, the Veteran has at no time exhibited impairment of thought processes. Also, he is able to communicate without speech problems of the kind contemplated by the criteria for a higher rating. The Board thus finds that the kinds of problems he experiences are most like those set forth in the criteria for a 50 percent rating. Consequently, the Board finds that, for the entirety of the period beginning October 19, 2010, the preponderance of the evidence is against the claim for a rating in excess of 50 percent for PTSD. The Board also finds that, for the entirety of the claim period, symptoms set forth in the criteria for a total rating for the Veteran's PTSD have not been evident. Although his occupational and social functioning has been impaired, the evidence shows that the Veteran's symptomatology has not risen to the level of total occupational and social impairment. Problems akin to gross impairment of thought processes or communication have not been shown. To the contrary, he has consistently been found to have normal thought processes, with no hallucinations or delusions or problems with orientation or activities of daily living. In addition, he has never been found, by any physician or examiner, to experience irrelevant, illogical, or obscure speech. The Veteran's VA treatment providers have found no differently in their reports of treatment throughout the appellate period. In view of the lack of symptomatology consistent with a total disability rating, the Board finds that an evaluation of 100 percent is not warranted at any time during the period beginning October 19, 2010. The Board notes, as discussed above, that it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. Nonetheless, upon review of the relevant medical evidence discussed above, the Board finds that, for the entirety of the period beginning October 19, 2010, the Veteran's PTSD has been manifested by symptoms most nearly approximating occupational and social impairment with reduced reliability and productivity. See 38 U.S.C.A. § 5017(b); 38 C.F.R. §§ 3.102, 4.3, 4.130, Diagnostic Code 9411. Therefore, a rating in excess of 50 percent for the Veteran's PTSD is not warranted. In its analysis, the Board has considered the GAF score of 60 assigned to the Veteran in October 2012 by his VA treatment provider. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), the GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." It does not otherwise include impairment in functioning due to physical (or environmental) limitations. There is no question that the GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). Nevertheless, the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the evaluation issue; rather, they must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). The DSM identifies scores in the ranges of 51-60 as "moderate symptoms" such as flat affect and circumstantial speech or moderate difficulty in social or occupational functioning. The Board notes here that the Veteran has not displayed such symptoms as consistent suicidal ideation or severe obsessional rituals; nor has he been noted to engage in activities such as shoplifting. Rather, he has admitted only to occasional fleeting thoughts of death; but no formal suicidal ideation or plan was identified at any time during the appeal period. Further, although the Veteran has been noted to have difficulty maintaining social relationships, he has had some degree of success; he was noted at the July 2015 VA examination to be married and to enjoy spending time with his grandchildren as well as with a group of friends whom he saw during an annual fishing trip. Nothing about the Veteran's assigned GAF score, when considered in light of the other evidence of record-in particular his assessed level of occupational and social impairment-leads the Board to conclude that a rating in excess of the 50 percent assigned from October 19, 2010, is warranted. In so finding, the Board reiterates that the Veteran's assigned GAF score is not dispositive of the evaluation and must be considered in light of the actual symptoms of his disorder. In this case, the Board has found that the Veteran's symptomatology, as discussed above, is appropriately compensated by the 50 percent rating assigned from October 19, 2010. The above determination is based upon consideration of applicable rating provisions. For all the foregoing reasons, the Board finds that the Veteran's PTSD warrants a disability rating no higher than the 50 percent assigned for the period beginning October 19, 2010. 38 C.F.R. §§ 4.3, 4.7, 4.22, 4.130, Diagnostic Code 9411. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for increase, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The above determinations are based on consideration of the applicable provisions of VA's rating schedule. The Board finds that at no time has the disability under consideration been shown to be so exceptional or unusual as to warrant the referral for consideration of any higher ratings on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). Here, there is an absence of evidence of marked interference with employment (i.e., beyond that contemplated in the assigned evaluation), frequent periods of hospitalization, or evidence that the Veteran's PTSD, without consideration of other disabilities, has rendered impractical the application of the regular schedular standards. In that connection, the Board notes that the Veteran's symptoms are contemplated by the criteria discussed above. Thus, the criteria for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). It bears emphasis that the schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2015). Thus, based on the record before it, the Board does not find that the medical evidence demonstrates any unusual disability with respect to the claim that is not contemplated by the rating schedule. The very symptoms the Veteran experiences are all addressed by the rating schedule. Thun v. Peake, 22 Vet. App. 111 (2008). As a result, the Board concludes that a remand for referral of the rating issue to the VA Central Office for consideration of extra-schedular evaluation is not warranted. Claim for a TDIU Entitlement to a total rating for compensation purposes based upon individual unemployability (TDIU) is warranted when a Veteran's service-connected disability or disabilities result in impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2015). TDIU may be awarded when the combined schedular rating for the service-connected disabilities is less than 100 percent and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Service connection is in effect for PTSD, evaluated as 50 percent disabling; this is his only service-connected disability. Accordingly, the Veteran's service-connected PTSD does not meet the schedular percentage requirements for entitlement to a TDIU under 38 C.F.R. § 4.16(a). As the Veteran does not meet the schedular requirements, the only remaining question in this case is whether he is unable to secure or follow a substantially gainful occupation as a result of his service-connected disability for purposes of an extra-schedular TDIU evaluation under 38 C.F.R. § 4.16(b). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Id. Therefore, at the RO level, rating boards are to submit to the Director, Compensation Service (Director), for extraschedular consideration, all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). The RO is to include in its submission a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment and factors having a bearing on the issue. 38 C.F.R. § 4.16(b). The Board itself cannot assign an extra-schedular rating in the first instance. Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). However, the Board can adjudicate whether to refer a case to the Director for an extra-schedular evaluation when the issue is either raised by the claimant or is reasonably raised by the evidence of record. Thun v. Peake, 22 Vet. App. 111, 115 (2008); Barringer v. Peake, 22 Vet. App. 242 (2008). If, and only if, the Director determines that an extra-schedular evaluation is not warranted, does the Board then have jurisdiction to decide the extra-schedular claim on the merits. Anderson v. Shinseki, 22 Vet. App. 423, 427-8 (2009); see also Floyd, 9 Vet. App. at 96-97 (stating that once the Board properly refers an extraschedular rating issue to Director for review, an appellant may "continue [ ] to appeal the extraschedular rating aspect of this claim"); see also 38 U.S.C.A. §§ 511(a) , 7104(a) (2014) ("All questions in a matter ... subject to decision by the Secretary shall be subject to one review on appeal to the ... Board."). Where, as in this case, a veteran fails to meet the applicable percentage standards, an extra-schedular rating is for consideration where the veteran is found unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b) (2015). Individual unemployability must be determined without regard to any non-service connected disabilities or a Veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19 (2015); see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a Veteran's favor. 38 C.F.R. § 4.3 (2015). Although the regulations do not provide a definition of "substantially gainful employment," VA Adjudication Procedure Manual, M21-1, Part IV, Subpart ii, 2.F.24.c defines the term as employment "at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the Veteran resides." Also, in Faust v. West, 13 Vet. App. 342 (2000), the Court defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a Veteran actually works and without regard to a Veteran's earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a Veteran is entitled to a TDIU is whether his service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a TDIU is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). The Veteran claims that he is unemployable as a result of his service-connected PTSD. He claims that his PTSD symptomatology is of such severity that he is rendered unable to obtain and retain gainful employment and that entitlement to a TDIU is thus warranted. The Veteran has undergone multiple VA examinations. At examinations in December 2006 and January 2009, the VA examiners specifically addressed the Veteran's employability. Each examiner noted the Veteran's report that he had left his job after 27 years due to back problems, not to his PTSD. In particular, the December 2006 VA examiner stated that the Veteran "quit work because of his back. He worked regularly and did not miss work because of psychiatric symptoms." Similarly, the January 2009 VA examiner stated that the Veteran's "PTSD symptoms never interfered with his ability to work or with his work performance. PTSD does not prevent him from working presently." In addition, the February 2008 VA examiner did not find the Veteran unemployable due solely to PTSD. Similarly, at a February 2009 VA treatment visit, the Veteran stated that he had retired early due partly to PTSD symptoms and partly to his non-service-connected back disability. In addition, the Veteran's award of disability benefits from the Social Security Administration (SSA) was based only in part on PTSD symptoms; the primary disability identified in the SSA award was a non-service-connected lumbar spine disorder. SSA examiners in March 2007 and July 2007 all found the Veteran to be able to maintain some employment despite his PTSD symptoms. The Veteran has also submitted evaluations from a private psychiatrist, dated in January 2008 and July 2009. In the January 2008 evaluation, the psychiatrist found the Veteran to be unable to work due both to his PTSD and to the non-service-connected back disorder. In the July 2009 assessment, however, the same examiner found the Veteran's PTSD alone rendered him unable to work. The Board agrees with the conclusions reached by the December 2008 and January 2009 VA examiners, as stated explicitly in both examination reports. Although the private psychiatrist opined in July 2009 that the Veteran is unable to work due to his service-connected PTSD, the Board affords this opinion little weight, particularly in light of the extensive and well-reasoned opinions provided in the December 2008 and January 2009 VA examiners' reports. This is particularly so given that the same private psychiatrist, just over a year before, had found that the Veteran's unemployability was due not only to PTSD but to non-service-connected disabilities as well. The Board thus finds that the private psychiatrist's opinions in this regard are of limited probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds the December 2008 and January 2009 VA examiners' reports to be more probative. The examiners conducted extensive psychological evaluation of the Veteran's PTSD symptomatology and specifically addressed the Veteran's concerns about his employability but both nevertheless specifically concluded that his inability to work is due at least in part to an unrelated back disorder. The Veteran himself confirmed these findings, stating at a February 2009 VA treatment visit that he had left his former job due not to PTSD but to back pain. The VA examination reports provide competent and probative evidence that the Veteran is not unemployable due solely to service-connected disability; the weight of the evidence is thus against a finding that the Veteran is unable to secure or follow a substantially gainful occupation as a result only of his service-connected disability. The Board does not doubt that the Veteran's service-connected PTSD causes him occupational impairment; this is addressed by his 50 percent disability rating. However, as noted by the December 2006 and January 2009 VA examiners, the Veteran retains the ability to work in at least some job settings; his inability to work is due at least in part to a non-service-connected back disability. This has been confirmed by the Veteran himself, at a February 2009 VA treatment visit, and by the private evaluator in January 2008. Thus, the Board does not find that the Veteran is unemployable due only to his service-connected PTSD. For the reasons and bases discussed above, the Board finds that a preponderance of the evidence is against the claim for entitlement to a TDIU, including on an extra-schedular basis, and this claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder for the period beginning October 19, 2010, is denied. Entitlement to a total disability rating based on unemployability due to service-connected disability (TDIU) is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs