Citation Nr: 1624377 Decision Date: 06/17/16 Archive Date: 06/29/16 DOCKET NO. 13-09 577 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an increased rating for paranoid schizophrenia, evaluated as 30 percent disabling prior to September 5, 2007. 2. Entitlement to an effective date earlier than September 5, 2007, for the grant of a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service in the U.S. Army from September 1972 to September 1974. This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from a December 2005 rating decision and a March 2011 Decision Review Officer Decision, of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. In September 2015, the Veteran testified at a videoconference hearing. A transcript of that hearing is of record. The claims file is now entirely in VA's secure electronic processing systems, Virtual VA and Veterans Benefits Management System (VBMS). The Board notes that during the pendency of this appeal, in a June 2007 rating decision, a 50 percent evaluation was assigned effective September 5, 2007; and a March 2011 rating decision awarded a 70 percent disability effective September 5, 2007. The RO noted that the increased rating issue for the period from September 5, 2007, was withdrawn by the Veteran on March 19, 2013. In fact, the Veteran's completed VA Form 9, Appeal to the Board of Veterans' Appeals, specifically stated that he was only appealing items 2 and 3 of the Statement of the Case, which dealt with the propriety of the September 5, 2007, date of the staged rating increase to 70 percent, and entitlement to an effective date prior to September 5, 2007, for the award of TDIU. Item 1 of the February 2013 Statement of the Case was the issue of entitlement to an increased evaluation of paranoid schizophrenia, then evaluated as 70 percent disabling as of September 5, 2007. As such, the Board finds that the issue of entitlement to an evaluation in excess of 70 percent since September 5, 2007 is not in appellate status. FINDINGS OF FACT 1. For the entirety of the appeal period, from July 14, 2005, to September 4, 2007, the Veteran's paranoid schizophrenia has been productive of occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. 2. From July 14, 2005, the Veteran's date of claim, to September 4, 2007, the Veteran's paranoid schizophrenia precluded him from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. From July 14, 2005 to September 4, 2007, the criteria for a 70 percent evaluation, but no higher, for paranoid schizophrenia have been met. 38 U.S.C.A. § 1155 (2014); 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9203 (2015). 2. From July 14, 2005, to September 4, 2007, the criteria for entitlement to a TDIU have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in September 2005, August 2007, and April 2008 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. Moreover, during the March 2013 Board hearing, the undersigned explained the issues on appeal and asked questions designed to elicit evidence that may have been overlooked with regard to the claim. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. Increased Rating for a Psychiatric Condition prior to September 5, 2007 Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, as here, the Veteran is requesting a higher rating for an already established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's paranoid schizophrenia has been rated as 30 percent disabling prior to September 5, 2007, and 70 percent disabling since September 5, 2007, pursuant to the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Codes 9411-9440, which provides that a noncompensable rating is warranted for a mental condition that has been formally diagnosed, but the symptoms of which are not severe enough either to interfere with occupational and social function or to require continuous medication. A 30 percent rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational task (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating also requires occupational and social impairment, but with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, 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 task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for even greater occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. The maximum rating of 100 percent requires total occupational and social impairment due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." See the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV); see also Carpenter v. Brown, 8 Vet. App. 240 (1995). According to DSM-IV, a GAF score of 71 to 80 indicates the examinee has, if at all, symptoms that are transient or expectable reactions to psychosocial stressors but no more than slight impairment in social, occupational or school functioning. A GAF score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. A GAF score of 31 to 40 indicates the examinee has some impairment in reality testing or communication or major impairment in several areas, such as work or school. A GAF score of 21 to 30 indicates that the examinee's behavior is considerably influenced by delusions or hallucinations, has serious impairment in communication or judgment, or is unable to function in almost all areas of life. Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). The RO certified the Veteran's appeal to the Board in July 2015; therefore, the claim is governed by DSM-5. The Board notes that the use of GAF scores has been abandoned in the DSM-5 because of, among other reasons, "its conceptual lack of clarity" and "questionable psychometrics in routine practice." See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). In this case, however, DSM-IV was in use at the time the medical entries of record were made. Thus, the GAF scores assigned remain relevant for consideration in this appeal. VA treatment records indicate that the Veteran had been treating for his psychiatric disorder since 1974. Although the VA treatment records from July 14, 2005, indicate fluctuations in the severity of his disability, there is sufficient evidence that his schizophrenia from July 14, 2005 to September 4, 2007, was productive of occupational and social impairment with deficiencies in most areas. The Veteran underwent VA examination in September 2005 at which time he denied being hospitalized for any emotional problems but noted that he continued in VA outpatient treatment at Jesse Brown in individual therapy and had been prescribed sertraline 100 mg in the morning and buspirone 10 mg in the morning. The Veteran reported that therapy seemed "to try to make the problems go away but they come back. Therapy pacifies my nerves." The Veteran reported that he remained unemployed "because of my condition, Hepatitis C, glaucoma, sugar up and down." He reported that he did not try to be social; that he got up between five and six, took his medication, tried to eat, exercised, shopped or paid bills, and read the Bible. The Veteran reported that he snacked during the day, that he ate more when he felt down, and that he thought that he had gained about 25 pounds in the prior seven-month period. The Veteran reported that he watched TV and that he did chores in the afternoon. The Veteran indicated that he tried to prepare balanced meals for himself and made sure that he ate before 6 p.m. because he had to take his insulin. The Veteran noted that his bedtime was usually between 10 and 11 p.m. He also reported that he seemed to be awakened intermittently until 4 o'clock in the morning when he could sleep for a good long while. The Veteran reported that his depression started after he got off drugs. He reported that he had crying spells but knew why he was crying. He reported being very irritable when angry. The Veteran reported that he prayed. He described his sleep as "bad" and his libido as reduced. He reported a fear of closed in spaces. He also reported that every time he looked at his bills, he had thoughts of suicide but he had never attempted, and had no plans or intent, to take his life. The Veteran indicated that he experienced daily auditory hallucinations of male and female voices, that male voices said rough things and the female voices said female things. He also indicated that he saw shadows. He reported that he was pretty suspicious, that he thought that he was being watched, and that people talked about him. The Veteran stated that he was most concerned that "sometimes I've put things in one place and find it in another place" which he reported happens twice a day. The Veteran was noted to experience ideas of reference. He thought that he has a mission to perform and that mission "has to do with him giving up drugs and being able to testify to others of his experience so that they will seek to avoid it and most of all to: confirm that there is help." On mental status examination, the Veteran was casually dressed with his hair neatly groomed. Initially he was somewhat wary, but he was never uncooperative. The Veteran's speech became quite normal as the interview progressed. His affect was appropriate to thought content, his mood was even, and he was well oriented to time, place and person. His general information was satisfactory, and he did not appear to be experiencing any perceptual disorder. Although he did not become delusional during the examination, the examiner noted that it was quite clear that initially he was a little wary. His abstract thinking, concentration, and memory were adequate. The Veteran was diagnosed as having schizophrenic disorder, and a GAF of 50 to 60 was assigned. VA treatment records from September 2005 to November 2005 indicate that the Veteran's psychiatric condition remained stable, however, in a December 15, 2005 letter, the Veteran's psychiatrist wrote, I am writing with regard to [the Veteran]. Although his mental status exam is very stable as far as active vegetative depressive symptoms, his depressive condition affects his ability to function. He hasn't been able to work in years. Several years ago he had a very serious depression but he did respond to medication with an improvement in his symptoms. As long as he stays on his medication, he looks good. Apparently his illness was diagnosed as Schizophrenia in the service but he most likely had an episode of Affective disorder. At the time he was diagnosed, Schizophrenia was a frequent diagnosis for patients, even if the patient's disorder was really an affective disorder. The patient's main deficit[s] are in the re[a]lm of social functioning and work capacity. His social activity consists basically of attending church. He is not friends with anyone in the Congregation because he has feelings that people are phony, jealous, and want to hurt him. He, therefore, stays away from people. He last tried to work a few years ago but couldn't function at his job. In addition to his depression, he has serious medical problems which interact with his social and work deficits, making it difficult for him to see, work at a good speed on a job, or interact with people on the job. Therefore, in spite of appearing stable, [the Veteran] has residual problems related to his psychiatric disorder. In a May 2006 Addendum, the Veteran's treating psychiatrist stated, I am updating [the Veteran]'s assessment. This patient appears stable when on observation but he has a serious depressive disorder which apparently started in the service. He was diagnosed as having Schizophrenia then which was a diagnosis that was often given at that time. I must assume that he had a Psychotic depression in the service. I have seen [the Veteran] in a very depressed state where he functioned poorly but with antidepressant medication he is able to come to appointments and live independently. But he continues to exhibit deficits which make him unable to function in a competitive work environment. He gets anxious, he does hear voices, and he has trouble concentrating. He is often irritable and argumentative which causes clashes with authority figures and would render working impossible. He also has serious medical problems which make his deficits even more disabling. He is diabetic and he has poor vision due to his diabetes and his glaucoma. He is unable to work due to his psychiatric and physical disabilities. VA treatment records dated from May 2006 to August 2007 chronicle the Veteran's obsession with his claim for increased rating as well as his somewhat inappropriate behavior of making demands with respect to medication and hospitalization and insisting upon seeing his psychiatrist outside his scheduled appointments. The Veteran also voices suicidal and homicidal thinking especially when his demands were not met and essentially accusing his psychiatrist of keeping him from achieving his goals. In June 2006, the Veteran's psychiatrist noted that the Veteran was definitely unraveling over the issue of not being hospitalized for 21 days in order to receive a 100 percent rating for his schizophrenia and he needed help in coping with his anger and upset. The psychiatrist noted that it was a crisis situation but that she did not believe that the Veteran was acutely homicidal. In July 2006, the psychiatrist noted that she and the Veteran were engaged in a conflictual relationship, that she offered to transfer him to a specific psychiatrist but that he wanted to pick his own psychiatrist so that he can make sure the psychiatrist who he sees will put veterans first and save him from "drowning." The psychiatrist noted that if the RO decision was not favorable, she believed that the Veteran was going to become very symptomatic. In October 2006, the Veteran reported his psychiatrist to her supervisors and the Director, but he refused transferring to another provider. The psychiatrist noted that she read one of the letters he sent the director and that it did not make sense. The psychiatrist noted that there seemed to be a possible thought disorder. The Veteran was offered antipsychotic medication to see if that would help him to think more clearly. In November 2006, the provider noted that the Veteran had been stable for years but since the last treatment plan update, he had had multiple crises. In addition to his medical problems, he became over-focused on obtaining 100% service-connection for his psychiatric disorder since December 2005 when his claim was rejected. The psychiatrist's inability to provide help with his financial situation resulted in his becoming anxious, agitated, hostile and demanding. When his request for a 21 day Acute Psychiatric Hospitalization was rejected (such hospitalization would give him immediate 100% service connection), he became threatening to himself and others. He was advised that the acute hospital is no longer used for long term treatment. Day hospital, PRRPT, and short term inpatient care were offered to him because of his increasing hopelessness and helplessness; but he refused. The psychiatrist noted that the Veteran's inability to handle stress and solve problems in a rational way was a serious deficit and contributed to his inability to manage his limited finances and his medical issues. A GAF of 45 was assigned. In August 2007, the Veteran's psychiatrist noted that the he had been very angry at her for a couple of years for what he saw as her failure to obtain appropriate benefits for him and that it was felt that it was in his best interest to start fresh with a new psychiatrist. At the initial evaluation with his new treating psychiatrist that same day, the Veteran reported that he felt mistreated, not treated well enough in the course of his VA medical care or his dealings with the VA for service connection. The psychiatrist noted that before medication, the Veteran had low mood, mood changes, hallucinations, suicidal feelings. The Veteran admitted to suicidal thinking but denied specific suicide attempts and specific homicide attempts. The Veteran reported that he has gotten angry and warned others in anger, "Don't press my button." The Veteran endorsed rapid thoughts, hallucinations (voices) (even off drugs), even hearing a voice "in the last five minutes, I believe it was the voice of the devil, it was negative, something to do with killing, something violent." The Veteran stated that if he listened to the voices he could get himself in trouble, whereas if he prays, goes to meetings, "learns how to control your thoughts," he does better. On mental status examination, the psychiatrist noted some intermittent eye contact and questioned whether there was a provocative and at the same time paranoid stance. The Veteran's speech was intense, could be run-on but interruptible, not soft. His thought process was circumstantial and tangential with no flight of ideas, question of looseness of association. His thought content included themes of interpersonal conflicts; being mistreated, insulted, criticized, and treated badly; suspicion of exploitation/deceit/hidden agenda; reluctance to confide regarding his fear of malicious intent; feeling demeaned by benign remarks or behavior. There were no frank delusions but the psychiatrist questioned the possibility. There was no suicidal or homicidal ideation, plan, intent, but he implied he was capable of harming others if someone crossed him. There were no signs of internal stimulation such as hallucinations but he admitted to voices at that time. His affect was blunted versus flattish; his mood was irritable, and there was some intensity to tone, frustration, and agitation. His insight was questionable with respect to the connection between his own thought/actions and the treatment he sometimes felt he got. Judgment was noted to be good in seeing the doctor. He was oriented to date and time of appointment. The psychiatrist stated, This patient has a history of one major depression or depression nos in the context of severe stressors, financial and medical (DM, HCV untreated, past repeated mild head injury exacerbating the irritability, lability component perhaps) but today reports experience of voices, has a paranoid stance in the appointment, has a history as per [previous psychiatrist] of very disorganized writings consistent with thought disorder as well as threatening verbal behavior towards her, so that depression with psychotic features, schizoaffective and bipolar disorder may be in the differential. The chronicity of and level of paranoia along with the cited effort to control himself and his voices are more consistent with the thought disorder rather than the affective disorder side of the contin[uu]m. His financial problems of being overextended in the past may be associated with an episode of mania in the past. The nonbizarre nature of his paranoia and suspicion of malevolence can be considered consistent with delusional disorder. He comes across as a patient with symptoms of paranoid personality disorder, with perhaps some cluster B features, with a later history [] of depression until his history of ongoing but mildly threatening voices and the chronicity of his paranoia come to the forefront. A low dose neuroleptic medication may be in order for this patient. He is fifty-four years old with significant substance dependence history and may be experiencing a mild cognitive decline, which can be tested in a future appointment. His current medical status can exacerbate the affective component of his presentation and may warrant a trial of anticonvulsant medication. His presentation may warrant an EEG and MRI should violence history increase and become more compelling. I discussed his medications and had some suggestions for him, asking him to think over this interview and bring in his questions next time and we can start from there. The psychiatrist noted that the working diagnosis from contact with the Veteran was schizoaffective disorder, depressed type manifested by delusions when ill, odd beliefs, inflated self-esteem or grandiosity, hallucinations in past, unusual perceptual experiences, incoherence in writing, loosening of associations in past, digressive speech and writing, overelaborate speech, pressure to keep talking, inappropriate affect, irritability, depressed mood most of day nearly every day during periods of depression in the past. Differential diagnoses included depression with psychotic features, bipolar disorder, psychosis nos, and persecutory delusional disorder with his affective component exacerbated by medical disease (unstable blood sugars of DM, fatigue with ongoing viral disease, past repeated mild blow to his head, past drug dependence.) The psychiatrist also diagnosed diagnoses of Paranoid Personality Disorder versus Personality disorder with cluster A and some B traits. A GAF of 40 was assigned. The psychiatrist noted the following stressors: lives with what sound like psychotic symptoms without medications, unemployed, never married, has behavior which alienates medical staff who have tried to help him. The initial treatment plan included change in psychiatrist, in addition to medications taken at the time. The psychiatrist was also considering an anticonvulsant and a neuroleptic for his voices and paranoia. That same month, the Veteran's former treating psychiatrist provided updated information for his increased rating claim. She stated, Since my last update in May 2006, the situation with the patient escalated due to a deterioration in his mental status. He has been obsessed with his claim for disability and began visiting the director's office almost weekly to complain about the mistreatment by the VA and by this psychiatrist. He wrote multiple letters to the Director and Assistant director. I read a letter and the thought content was disorganized and incoherent. This would indicate a thought disorder which is a key component of a diagnosis of Schizophrenia. In addition he became increasingly hostile toward this psychiatrist developing a psychotic transference where he blamed her for all his problems. He also complained of continued mistreatment from the VA and this physician. This thinking appears to be paranoid and was rather alarming. This necessitated a transfer to another psychiatrist who could look at this patient in a fresh way. He saw [another psychiatrist] on August 13, 2007 and she did a complete evaluation of [the Veteran]. Her notes are in the electronic record. She diagnosed the patient as having [s]chizoaffective disorder. I would agree with that. He comes across initially as well put together but under the stress of his financial problems, increasing medical problems and the stress of an unfavorable decision of his claim for increased disability, he has deteriorated. It is now obvious that he has a thought disorder and paranoid thinking. This man is quite ill and unable to work. It appears that the VA providers and examiners have considered all of the Veteran's psychiatric symptoms as part and parcel of his service-connected paranoid schizophrenia. See Mittleider v. West, 11 Vet. App. 181 (1998) (regulations require that when examiners are not able to distinguish the symptoms and/or degree of impairment due to a service-connected versus a non service-connected disorder, VA must consider all of the symptoms in the adjudication of the claim). Therefore, the findings of record indicate that from July 14, 2005 to September 4, 2007, the Veteran's schizophrenia symptoms match most of the rating criteria for a 30 percent rating (depressed mood, anxiety, suspiciousness, chronic sleep impairment), most of the criteria for a 50 percent rating (flattened affect; circumstantial, circumlocutory, stereotyped speech; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships), and some of the criteria for a 70 percent rating (impaired impulse control; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships). In addition, GAF scores assigned during the appeal period range from 40 to 60. The record indicates that in July 2005, he was already having issues with becoming irritable, becoming angry, and making unrealistic demands. At the VA examination in September 2005, he reported crying spells, irritability, anger, thoughts of suicide, daily auditory hallucinations. In addition, although the Veteran's treating psychiatrist until August 2007 noted that the Veteran appeared stable, she noted in December 2005 that his psychiatric condition affected his ability to function, that his main deficits were in the re[a]lm of social functioning and work capacity, and that he had not been able to work in years. The psychiatrist noted that in spite of appearing stable, the Veteran had residual problems related to his psychiatric disorder. The Board finds that the psychiatrist's statement essentially equates to an opinion that the severity of the Veteran's symptoms were worse than they appeared on examination. Thus, combined with the symptoms of hallucinations and suicidal ideation, the Board finds that during the appeal period from July 14, 2005 to September 5, 2007, the Veteran's symptoms of his service-connected paranoid schizophrenia equate in severity, frequency and duration to the criteria for a 70 percent evaluation; in essence, the totality of the evidence indicates his psychiatric condition has been productive of occupational and social impairment with deficiencies in most areas. During this time, however, the Veteran's paranoid schizophrenia symptoms did not approach the severity contemplated for the 100 percent rating. As set forth above, the criteria for a 100 percent rating are met when the Veteran experiences total occupational and social impairment, which is not demonstrated in this case. Although it appeared to his psychiatrists that he may have wanted to hurt himself and others, he was never involuntarily admitted to the hospital as a result of these appearances. Further, there is no indication in the record from July 14, 2005 to September 4, 2007, that the Veteran ever had intermittent inability to perform activities of daily living or had a problem with hygiene. The record indicates that he lived alone and paid his bills. At the September 2005 VA examination, the Veteran reported that he lived alone in a townhouse, shopped, prepared his own meals, and paid his bills. Further, from July 14, 2005 to September 4, 2007, the Veteran had been consistently oriented. Thus, the evidence weighs against a finding of gross impairment in thought processes or communication. Overall, the examination reports show that from July 14, 2005 to September 4, 2007, he was independent with his activities of daily living and oriented to person, place, and time. Although the Veteran no doubt had difficulty with work and social relationships, the evidence from July 14, 2005 to September 4, 2007, did not reflect total occupational and social impairment. The Veteran reported having a girlfriend and attending church. Therefore, a 100 percent rating is not warranted from July 14, 2005, his date of claim, to September 4, 2007. Effective Date for TDIU The effective date of an evaluation and award of compensation based on a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400(o)(1) (2015). The effective date of an award of increased compensation may, however, be established at the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the application for an increased evaluation is received within one year from that date. 38 U.S.C.A. § 5110(b)(2) (West 2014); 38 C.F.R. § 3.400(o)(2) (2015). In general, three possible dates may be assigned depending on the facts of a case, (1) if an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400(o)(1) (2013)); (2) if an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (factually ascertainable) (38 C.F.R. § 3.400(o)(2) (2013)); or (3) if an increase in disability precedes the claim by more than a year, the date that the claim is received (date of claim) (38 C.F.R. § 3.400(o)(2) (2013)). Thus, determining an appropriate effective date for an increased rating under the effective date regulations involves an analysis of the evidence to determine (1) when a claim for an increased rating was received and, if possible, (2) when the increase in disability actually occurred. 38 C.F.R. §§ 3.155, 3.400(o)(2) (2015). Where the record reasonably raises the question of whether the Veteran is unemployable due to a service-connected disability, the issue of entitlement to a TDIU rating is part and parcel of the higher rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, in light of Rice, for the purposes of this decision, the Board will use the date of July 14, 2005, the date his claim for an increased rating for his psychiatric condition was received, as the date of the claim for a TDIU. There is no indication of a pending TDIU claim prior to this date. The remaining question is on what date did entitlement to a TDIU arise, and whether that date is before or after July 14, 2005. Under the applicable regulations, a TDIU may be granted only when it is established that the service-connected disability is so severe, standing alone, as to prevent the retaining or obtaining of substantially gainful employment. Under 38 C.F.R. § 4.16, if there is only one service-connected disability, it must be ratable at 60 percent or more to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Board has granted herein a 70 percent evaluation for the Veteran's paranoid schizophrenia from July 14, 2005. He is, thus, eligible for consideration of a TDIU on a schedular basis from that date. VA's General Counsel has concluded that the controlling VA regulations generally provide that Veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. It was also determined that "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2,317 (1992). For a Veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places the claimant in a different position than other Veterans with the same disability rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the particular Veteran is capable of performing the physical and mental acts required by employment, not whether that Veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In discussing the unemployability criteria, the Court, in Moore v. Derwinski, 1 Vet. App. 83 (1991), indicated in essence that the unemployability question, i.e., the ability or inability to engage in substantial gainful activity, must be looked at in a practical manner, and that the thrust of the inquiry was whether a particular job was realistically within the capabilities, both physical and mental, of the Veteran involved. As noted above, the VA psychiatrist's December 2005 letter noted that the Veteran's main deficits were in the re[a]lm of social functioning and work capacity. He had last tried to work a few years before but could not function at his job. In May 2006, that same psychiatrist elaborated that the Veteran exhibited deficits which made him unable to function in a competitive work environment and noted that he got anxious, heard voices, and had trouble concentrating. The psychiatrist noted that the Veteran was often irritable and argumentative which caused clashes with authority figures and would render working impossible. The evidence indicates that the Veteran reported going to barber school and then to beauty school. With the symptoms he exhibited from July 2005 to September 2007, it is difficult for the Board to believe that the Veteran would be able to work in any field where he had to be in contact with people in any capacity. Thus, as noted above, although the Veteran's schizophrenia symptoms have fluctuated over the course of the appeal starting July 14, 2005, resolving all doubt in the Veteran's favor, the Board finds that the Veteran's service connected schizophrenia precluded him from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience from essentially the same time period. Therefore, the Board finds that an effective date of July 14, 2005, is appropriate for a TDIU, as it is the date of claim and giving the Veteran the benefit of the doubt, also the date entitlement arose. ORDER From July 14, 2005 to September 4, 2007, entitlement to an evaluation of 70 percent for service-connected paranoid schizophrenia is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an effective date of July 14, 2005, for the award of a TDIU is granted subject to the law and regulations governing the payment of monetary benefits. ______________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs