Citation Nr: 1640837 Decision Date: 10/18/16 Archive Date: 11/08/16 DOCKET NO. 14-11 594 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial rating in excess of 50 percent for service-connected psychotic disorder, not otherwise specified (NOS). 3. Entitlement to a total disability rating based upon individual unemployabiltiy (TDIU) due to service-connected disabilities from September 12, 2009 to March 12, 2014. REPRESENTATION Veteran represented by: Penelope E. Gronbeck, Esq. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from August 1973 to April 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which granted entitlement to service connection for psychotic disorder, NOS, and assigned a 10 percent evaluation effective the September 12, 2009 date of claim. The decision also denied service connection for PTSD. The Veteran timely appealed the initial rating assigned as well as the denial of service connection. In June 2016, the Veteran presented sworn testimony during a personal hearing in Washington D.C., which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims file. In August 2016, the Veteran, through his attorney, submitted additional evidence directly to the Board. At that time, the Veteran also submitted a written waiver of local consideration of this evidence; this waiver is contained in the VA claims file. See 38 C.F.R. §§ 19.9, 20.1304(c) (2015). In a March 2014 rating decision, the Veteran's initial rating for service-connected psychotic disorder, NOS, was increased to 50 percent, effective from the date of claim. The Veteran has not expressed satisfaction with the increased disability rating; this matter thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The Court has held that a claim for a TDIU is an element of a claim for a higher initial rating or increased rating when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). For the reasons indicated below, the Board finds that the issue of entitlement to a TDIU has been raised as part and parcel of the claim for an initial rating higher than 10 percent for psychotic disorder. The Board notes that the Veteran is now in receipt of a TDIU from March 12, 2014. See February 2015 rating decision. Therefore, the Board must consider the Veteran's entitlement to a TDIU prior to March 12, 2014, beginning on the effective date of the grant of service connection for psychotic disorder and assignment of the initial 10 percent rating, September 12, 2009. FINDINGS OF FACT 1. The probative evidence of record indicates that the Veteran does not meet the diagnostic criteria for a diagnosis of PTSD. 2. The Veteran's psychotic disorder, NOS, has been manifested by occupational and social impairment, with deficiencies in most areas, but has not more nearly approximated total occupational and social impairment. 3. From September 12, 2009 to March 12, 2014, the evidence is at least evenly balanced as to whether the Veteran's service-connected disabilities to include psychotic disorder, NOS, precluded him from securing or following substantially gainful employment consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. PTSD was not incurred in or aggravated by the Veteran's military service. 38 U.S.C.A. §§ 1110, 1131, 1154(b), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2015). 2. The criteria for an initial disability rating of 70 percent, but no higher, for psychotic disorder, NOS, are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code (DC) 9210 (2015). 3. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to a TDIU from September 12, 2009 to March 12, 2014, are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.129(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that claimant is expected to provide. In Dingess v. Nicholson, 19 Vet. Ap. 473 (2006), the Court held that, upon receipt of an application for a service connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. As to the psychotic disorder, NOS claim, where, as here, service connection has been granted and the initial rating and effective date have been assigned, the claim of service connection has been more than substantiated. It has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473,490-491 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As to the service connection claim, letters dated October 2009, December 2009, and February 2010 notified the Veteran of the evidence not of record that was necessary to substantiate his claim. He was told what information he needed to provide, and what information and evidence VA would attempt to obtain. He was also provided with the requisite notice with respect to the Dingess requirements. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied. With respect to VA's duty to assist, the Veteran's service treatment records (STRs), as well as VA and private treatment records have been obtained and associated with the claims file. The Veteran was also afforded a pertinent VA examination in August 2012. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The VA examination obtained here is sufficient, as the examiner considered all of the pertinent evidence of record, including the statements of the Veteran, and provided explanations for the opinion stated as well as the medical information necessary to apply the appropriate rating criteria. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the pending claims has been met. 38 C.F.R. § 3.159(c)(4). II. Service connection claim Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). 38 C.F.R. § 4.125(a) provides that, if the diagnosis of a mental disorder does not conform to the DSM-IV or is not supported by the findings on an examination report, the report must be returned to the examiner to substantiate the diagnosis. VA has amended 38 C.F.R. § 4.125(a) to require the diagnosis to conform to DSM-5. See Schedule for Rating Disabilities-Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14308 (Mar. 19, 2015). A necessary element for establishing any service connection claim is the existence of a current disability. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran filed his claim of entitlement to service connection for PTSD in September 2009. His claim must be denied because the preponderance of the evidence reflects that he has not had PTSD since that time. VA treatment records dated February 2005 document diagnoses of depression, NOS, and "rule-out PTSD (related to daughter's death)." A VA examination conducted in July 2005 noted diagnoses of amphetamine dependence, cannabis dependence, depressive disorder, NOS, substance-induced mood disorder, and substance-induced psychotic disorder with hallucinations. A March 2009 VA mental health intake evaluation confirmed diagnoses of impulse control disorder, NOS, as well as major depressive disorder. Notably, PTSD was not diagnosed at either the July 2005 VA examination or the March 2009 VA mental health intake evaluation. Similarly, although a VA treatment provider noted the Veteran's complaints of increased symptoms of PTSD in September 2010, a continuing diagnosis of PTSD was not indicated. A June 2010 psychiatric examination was conducted for Social Security Administration (SSA) purposes, at which time diagnoses of PTSD and major depressive disorder under the DSM-IV criteria were indicated. Critically, although the June 2010 examiner diagnosed the Veteran with PTSD, he failed to address whether the PTSD is related to the Veteran's military service, as opposed to his family stressors including childhood physical and sexual abuse, as well as the murder of his daughter. In a March 2011 statement, Dr. K.J., a VA psychologist, indicated that the Veteran "suffers from PTSD and depression related to his combat experience." However, contrary to Dr. K.J.'s statement, a PTSD diagnosis is not corroborated by the Veteran's VA treatment records. The Board additionally notes that the Veteran has not contended, nor is there any evidence to suggest, that he participated in combat during his military service. Moreover, there is no indication that the PTSD diagnosis noted by Dr. K.J. was rendered upon the application of the DSM criteria as is required to sustain a claim of entitlement to PTSD pursuant to 38 C.F.R. § 3.304(f). Accordingly, the Board affords the March 2011 letter from Dr. K.J. little probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). In contrast, the Veteran was afforded a VA psychiatric examination in August 2012, at which time the VA examiner interviewed the Veteran and thoroughly reviewed his medical history. The examiner determined that the Veteran's "symptoms do not meet the diagnostic criteria for PTSD under the DSM-IV criteria." Rather, the examiner diagnosed the Veteran with personality disorder, NOS, depressive disorder, NOS, and psychotic disorder, NOS. Similarly, the Veteran, through his attorney, submitted a private psychological evaluation dated July 2016 in which the examining psychologist interviewed the Veteran and thoroughly reviewed his medical history. The examiner determined that, "[b]ased on all evidence, [the Veteran] meets criteria for diagnoses of schizophrenia and polysubstance abuse in sustained remission." The examiner further indicated, "it appears that a schizophrenia diagnosis better accounts for this presentation than a depression diagnosis." When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez, 22 Vet. App. at 304. As the psychologists who conducted the August 2012 VA examination and the July 2016 private psychological evaluation explained the reasons for their conclusions based on accurate characterizations of the evidence of record and detailed examination findings, their opinions that the Veteran does not have PTSD are entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Moreover, the findings of the August 2012 and July 2016 examinations are consistent with the Veteran's VA treatment records, which do not confirm a continuing diagnosis of PTSD. The August 2012 VA examination report and the July 2016 private psychological evaluation are therefore the most probative medical opinions in the evidence of record. To the extent that the Veteran claims that he has PTSD as opposed to a different psychiatric disorder, his testimony is not competent. Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"). In addition, the regulation specifically provides that service connection for PTSD requires medical evidence diagnosing this disorder. Accordingly, where, as here, there is competent and persuasive medical evidence establishing that the Veteran does not have PTSD, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the first essential criterion for a grant of service connection, evidence of a current PTSD diagnosis, has not been met. In reaching the above conclusions, 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, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. III. Initial rating claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating 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 the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Veteran was assigned a 50 percent evaluation for his service-connected psychotic disorder, NOS, from September 12, 2009, the date of claim. Psychotic disorder, NOS, is evaluated pursuant to 38 C.F.R. § 4.130, DC 9210. Under this formula, a 50 percent evaluation is for assignment when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty establishing effective work and social relationships. A 70 percent evaluation is contemplated for 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. A 100 percent evaluation is warranted when there is evidence of 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 and place; memory loss for names of close relatives, own occupation or name. The Global Assessment of Functioning (GAF) is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). As will be discussed below, the Veteran has been assigned GAF scores ranging from 37 to 50 as determined by treatment providers, the June 2010 SSA evaluating psychiatrist, and the August 2012 VA examiner. These scores are indicative of serious impairment; in particular, scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing in school). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). When determining the appropriate disability evaluation to assign, the Board's primary consideration is the veteran's symptoms, but it must also make findings as to how those symptoms impact the veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In this matter, the Veteran has demonstrated a complex psychiatric disability picture throughout the appeal period. Clinicians have assessed and excluded various diagnoses. In general, his psychiatric symptoms during this period appear attributable to service-connected psychotic disorder, NOS, or schizophrenia or at least not clearly separable from the service-connected disability. Mittleider v. West, 11 Vet. App. 181 (1998). Thus, all psychiatric symptoms are considered part of the service-connected psychotic disorder, NOS, diagnosis. Id. For the following reasons, an initial rating of 70 percent is warranted under the schedular criteria for the entire appeal period. Here, a March 2009 VA mental health intake evaluation noted the Veteran's report of anger and difficulty with authorities. The Veteran described his outbursts of anger as "explosions." He states that he becomes verbally abusive, but denies any physical abuse. The Veteran endorsed interrupted sleep. He is twice divorced and currently engaged. He resides with his fiancé and a close friend. The Veteran has six children. He reported that he previously worked as a truck driver and was last employed two to three years ago. The treatment provider noted that the Veteran was alert and well-oriented. He exhibited psychomotor agitation of all extremities. His speech was fast and of normal volume. He was irritable. He did not endorse suicidal or homicidal ideation. He denied auditory or visual hallucinations. His thought process was linear; his insight and judgment were limited. The treatment provider diagnosed the Veteran with impulse control disorder, NOS, and major depressive disorder. A GAF of 50 was assigned. In a June 2010 psychiatric examination for SSA purposes, it was noted that the Veteran reported problems with an explosive temper. He stated that he does not become physically violent. He endorsed sleep issues including nightmares. He also endorsed hypervigilance and exaggerated startle response. The Veteran said he frequently feels depressed; however, he denied suicidal thoughts or attempts. His interest in and ability to enjoy things has significantly decreased. He has no energy or motivation. The Veteran also reported impairment of concentration and memory. The examining psychiatrist noted that the Veteran has significant anxiety, and exhibited "notable psychomotor retardation." The Veteran denied a history of mania, but did endorse auditory hallucinations. He stated that the voices tend to bother him when he is very depressed or angry. He endorsed a history of on-going substance abuse problems including marijuana use. He currently lives with his girlfriend and her daughter. He stated that he does not have a social life outside of his family. The Veteran's grooming and hygiene were fair. His thought process was linear and goal-directed. His speech was fluid with normal rate, tone, and volume. His mood was frustrated and irritated. His affect was full and irritable. The Veteran was alert and well-oriented. The examining psychiatrist noted that the Veteran "seems to be having more and more severe PTSD symptoms over the last 1-2 years . . . He is becoming increasingly isolative, which is an indicator of poor prognosis." The examiner concluded that the Veteran should be able to maintain regular attendance in a workplace and should be able to deal with the usual stress encountered in the workplace, although he has "significant problems with controlling his anger and yelling." A GAF of 37 was assigned due to moderate to severe impairment in multiple areas of functioning. A June 2010 VA treatment record noted the Veteran's report that he feels depressed and has difficulty falling/staying asleep. A September 2010 VA mental health note documented the Veteran's report of depression, disturbed sleep, and hopelessness. The Veteran denied suicidal ideation. He endorsed anger and "wishing others harm;" however, he denied homicidal ideation. The treatment provider described the Veteran as fairly neat in appearance with fair grooming. The Veteran was alert and well-oriented. He exhibited normal speech and a depressed/irritable mood. His affect was mildly depressed. The treatment provider noted that the Veteran complained of increasing anger over the last year. He further explained that the Veteran has a supportive girlfriend and has participated in some anger management, but continues to be explosive at times. The Veteran was afforded a VA psychological examination in August 2012 at which time the examiner confirmed diagnoses of personality disorder, NOS, depressive disorder, NOS, and psychotic disorder, NOS. The examiner attempted to differentiate between the symptoms caused by the disabilities, but ultimately was unable to definitely separate out the occupational and social impairment caused by each disability. See also the VA addendum opinion dated December 2012. The examiner opined that the Veteran's psychiatric disabilities manifested in "[o]ccupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." In obtaining the Veteran's social history, the August 2012 VA examiner noted that the Veteran has not earned a GED or high school diploma. He has been twice married, and has a total of six children. He and his current partner have been together since 2006 and currently live together. The Veteran reported that he spends most of his time watching movies, cleaning/maintaining his car, talking with his partner, and playing games on the computer. He stated that he has friends and enjoys talking, playing games, listening to music, and playing the guitar. He reported that he sees friends an average of twice per week. He has not worked since 2008, when he reportedly lost his job due to medical issues including physical and psychological disabilities. The examiner opined that the Veteran's "problems with temper (rising to the point of violence in the past) [have] a significant impact on his work functioning." The examiner further noted the Veteran's report of auditory and visual hallucinations. The Veteran is suspicious, irritable, and does not cooperate with authority. The examiner explained, "[i]t is likely that he would find working under a supervisor a stressful and unhappy experience." The Veteran endorsed intrusive thoughts, markedly diminished interest or participation in significant activities, difficulty falling or staying asleep, and irritability or outbursts of anger. He additionally reported depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, impaired judgment, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and impaired impulse control, such as unprovoked irritability with periods of violence. A GAF of 49 was assigned. A VA addendum opinion was obtained in December 2012 from the August 2012 examiner in an effort to clarify whether the Veteran's level of work impairment related specifically to his psychotic disorder, NOS. To this end, the examiner provided the following opinion: Recent medication management notes from Dr. Johansen indicated that [the Veteran] is being treated with Aripiprzole (15mg) and is not suffering from any significant symptoms of psychosis. Stress often has a negative impact on psychotic symptoms and if he were in a stressful work environment, he would likely be more symptomatic (in terms of hallucinations) than he is currently. According to his statements during the interview, the primary reason area of work impairment is related to his physical medical problems. His psychotic disorder has a mild impact on his work functioning (some suspiciousness) at this time, but if he were in a stressful work environment he could quickly become much more symptomatic. At the June 2016 Board hearing, the Veteran testified that he is learning to deal with his stress, but used to explode and "would make a mess out of my job or out of my relationships." See the June 2016 Board hearing transcript, pg. 8. He clarified that he has "problems trying to explain myself." Id. He endorsed problems with focusing and short-term memory. Id. He stated that he has been married for ten years. His wife helps take care of him due to his problems with memory and concentration, as well as anxiety and paranoia. Id. at pgs. 8-9, 11. The Veteran reported that he last worked in April 2008. He stated that, although he stopped working due to a physical disability, the foreman told him that he had an attitude problem and the employer was probably going to replace him anyway. Id. at pg. 10. In support of his claim, the Veteran, through his attorney, recently submitted a private psychological evaluation dated July 2016. The Veteran reported that he lives with his partner; his daughters provide him with transportation to appointments. He has seven living adult children and fourteen grandchildren. He is estranged from some of his children. He reported a history of aggressive and assaultive behavior, which the examiner indicated "appears to be connected to his history of amphetamine use, and since becoming sober, this behavior ha[s] largely disappeared." The Veteran was last employed in 2007; he reported that he was terminated for being overly argumentative and forgetting assignments. The examiner reported that the Veteran was alert and well-oriented during the evaluation. The Veteran's speech was rapid, tangential, and often disorganized. The examiner explained, "[t]here was distinct pressure in his speech, and thought blocking was evident." The Veteran described his mood as paranoid. He was anxious and sweated during the interview. His affect was "distinctly anxious." He endorsed vague fears about the government, on which he struggled to elaborate. The Veteran and his wife also reported periods of "frank delusions, such as the belief that he invented the Geico lizard mascot and had trained him to perform on television." The Veteran endorsed a sense that others are talking about him, or mean to harm him. He additionally reported auditory hallucinations, which occur most days of the week. The Veteran stated that the voices will wake him up from sleep, and distort what others say, or mimic the sound of other people; "such that he cannot be sure what a person has actually said versus what the voices are pretending they have said." The Veteran indicated that he has gotten into physical confrontations with others, believing that they have insulted or mocked him. He now does not go out in public without his wife as a mediator. The Veteran reports that when he is alone he holds conversations with his auditory hallucinations. The Veteran's thought process is nonlinear and disorganized. He also displayed severe short-term memory difficulty. The Veteran's wife reported that he can no longer cook for himself, as he will forget what is on the stove. He also reports difficulty remembering the steps to complete even fairly well-known tasks. His sense of time is "extremely poor, and he frequently will disappear for hours on end, believing [he has] only been away for a short time." The Veteran's spouse reported that, without continuous cueing, the Veteran "has difficulty remembering what day and what time it is." The Veteran also endorsed mood symptoms of anxiety, irritability, guilt, poor concentration, and ruminations over his perceived deficits. He endorsed excessive anger or verbally blowing up at other people with little or no provocation. He denied current suicidal ideation. The Veteran reported difficulties remembering to perform basic hygiene. His insight is moderate and his judgment is variable. The examiner indicated that the Veteran "is profoundly limited and impaired by his schizophrenia" in social, occupational, and community functioning. The examiner indicated that the Veteran is "permanently and totally" disabled as a result of his schizophrenia. Based on the above, the Board finds that the impact of the Veteran's psychotic disorder, NOS, symptoms on his social and industrial functioning is sufficient to approximate the degree of impairment contemplated by a 70 percent rating. While the GAF scores have generally reflected levels of serious impairment, neither GAF scores nor an examiner's characterization of the degree of the disability are dispositive of the legal questions involved in determining the appropriate rating for psychotic disorder, NOS. 38 C.F.R. § 3.100(a) (2015) (delegating the Secretary's authority "to make findings and decisions ... as to the entitlement of claimants to benefits" to, inter alia, VA "adjudicative personnel"); 38 C.F.R. § 4.2 ("It is the responsibility of the rating specialist to interpret reports of examination ... so that the current rating may accurately reflect the elements of disability present."); VA Adjudication Procedures Manual, M21-1, Part III, Subpart. iv, Chapter 3, Section A.7.i (updated Oct. 28, 2015) ("Do not request a medical authority to make conclusions of law, which is a responsibility inherent to the rating activity"). The symptomatology associated with the Veteran's service-connected psychotic disorder, NOS, to include that indicated by the lay statements and treatment records, supports the assignment of a 70 percent rating because this disability has been shown to result in occupational and social impairment, with deficiencies in most areas, such as work, family relations, and mood, due to such symptoms as near-continuous depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control with periods of unprovoked irritability with outbursts of anger; difficulty in adapting to stressful circumstances; and the inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9210. Specifically, these symptoms have been endorsed by the Veteran, as corroborated by VA and private treatment providers/examiners. The evidence reflects that the Veteran's psychological symptoms have been relatively consistent and are of such severity as to warrant a 70 percent evaluation since the date of claim. Significantly, however, the symptoms have not at any point during the appeal period more nearly approximated total occupational and social impairment. In this regard, the Board recognizes that the Veteran was not consistently employed during the period under consideration, and it is undisputed that the Veteran experiences persistent auditory hallucinations. However, the evidence does not reflect that the symptoms have more nearly approximated total occupational and social impairment. Although he socially isolates himself, the Veteran does maintain regular contact with a few friends and certain family members including his wife and several of his children. His reported history of inability to establish and maintain effective relationships, irritability, impaired concentration, impaired memory, and auditory hallucinations are specifically contemplated in the criteria for a 70 percent rating. Moreover, although the Veteran's insight and judgment have been noted to be impaired, at times during the appeal period, there is no evidence that he has gross impairment in thought processes or communication. In spite of difficulties with time perception, the Veteran has been consistently well-oriented at both VA and private evaluations throughout the appeal period. Similarly, he has maintained basic hygiene, despite recognized deficits in memory and concentration. Thus, neither the symptoms nor overall level of impairment more nearly approximate the criteria for a 100 percent under the rating criteria, and an initial rating higher than 70 percent is therefore not warranted for the Veteran's psychotic disorder, NOS. The Board additionally finds that the Veteran's psychotic disorder, NOS, does not warrant referral for extraschedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular disability rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extraschedular disability rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability and the established criteria found in the rating schedule to determine whether a veteran's disability picture is adequately contemplated by the rating schedule. Id. If the disability picture is not adequately contemplated by the rating schedule, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Here, the rating criteria specifically address the Veteran's psychological symptomatology, including irritability, explosions of anger, depression, anxiety, auditory hallucinations, and impaired social and occupational functioning, as described above. Moreover, as indicated by the cases cited above, the criteria in the general rating formula for mental disorders include both the symptoms listed as symptoms "such as" those listed, along with the overall impairment caused by these symptoms. This broad language in the criteria thus contemplates all of the symptoms even though they are not specifically listed. Thus, the Board finds that the Veteran's disability picture is contemplated by the rating schedule, consideration of whether there has been marked interference with employment or frequent hospitalization is not required, and referral for extraschedular consideration is not warranted. In Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), the Federal Circuit held that "[t]he plain language of § 3.321(b)(1) provides for referral for extra-schedular consideration based on the collective impact of multiple disabilities." In this case, entitlement to a TDIU has been granted from the effective date of the grant of service connection for psychotic disorder. The Federal Circuit in Johnson indicated that the TDIU provision only accounts for instances in which a veteran's combined disabilities establish total unemployability, i.e., a disability rating of 100 percent. Id. at 1366. On the other hand, 38 C.F.R. § 3.321(b)(1) performs a "gap-filling" function. Id. It accounts for situations in which a veteran's overall disability picture establishes something less than total unemployability, but where the collective impact of a veteran's disabilities is nonetheless inadequately represented. Id. As the Veteran has been granted TDIU, he is deemed to have total unemployability and there is no "gap" to fill by § 3.321(b). Further discussion of an extraschedular rating based on the collective impact of multiple disabilities is therefore not warranted in this case. For the foregoing reasons, the preponderance of the evidence reflects that an initial rating of 70 percent, but no higher, is warranted for the Veteran's psychotic disorder, NOS. The benefit of the doubt doctrine is therefore not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. IV. Entitlement to a TDIU from September 12, 2009 to March 12, 2014. TDIU may be granted where the schedular rating is less than total and the service-connected disability precludes the Veteran from obtaining or maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2015). By this decision, the Veteran's service-connected psychotic disorder, NOS, has been found to be 70 percent disabling throughout the appeal period. As noted in the introduction, the Veteran is in receipt of a TDIU from March 12, 2014. Prior to March 12, 2014, the Board notes that the Veteran was also service-connected for status-post right middle finger injury at 10 percent disabling and pes planus at zero percent disabling, in addition to psychotic disorder, NOS, at 70 percent. Accordingly, it is undisputed that the Veteran meets the percentage requirements for consideration of TDIU under 38 C.F.R. § 4.16(a) prior to March 12, 2014. Thus, the question is whether his service-connected disabilities precluded gainful employment for which his education and occupational experience would otherwise qualify him prior to March 12, 2014. As described above, a psychiatric evaluation of the Veteran was conducted in June 2010 at which time the examiner determined that the Veteran should be able to maintain regular attendance in a workplace and should be able to deal with the usual stress encountered in the workplace, although he has "significant problems with controlling his anger and yelling." The Veteran was afforded a VA psychological examination in August 2012, at which time the examiner noted the Veteran's report that he has not attained a high school diploma or GED. The Veteran last worked for a meat packing plant in 2008. The examiner determined that the Veteran's diagnosed psychiatric disabilities manifested in "[o]ccupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." The examiner explained that the Veteran has not worked full-time since 2008, at which time he was forced to stop working as a general laborer due to problems related to physical disabilities, as well as his service-connected psychotic disorder, NOS. The Veteran was afforded a VA examination as to his service-connected bilateral pes planus in August 2012, at which time the Veteran reported that he can ambulate for 150-200 feet and then he must stop to rest due to cramps and aching in the arches of his feet. The examiner determined that the Veteran's pes planus causes him to be limited to sedentary employment with light to moderate activity with no standing/ambulation for more than 10-15 minutes at a time. As detailed above, in a December 2012 VA addendum opinion, the examiner reported that, although the Veteran's psychotic disorder, NOS, currently has mild impact on his occupational functioning because the Veteran is unemployed, were he to return to work, it would be stressful for him, which would cause his psychological symptoms (in particular, hallucinations) to become much more symptomatic. A VA Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits, which was completed by the Veteran's former employer indicated that he last worked in April 2008. He was dismissed from his job as a dock worker due to attendance problems. At the June 2016 Board hearing, the Veteran, through his attorney, asserted that he has been unemployable throughout the appeal period primarily as a result of his service-connected psychotic disorder, NOS. As described above, the Veteran submitted a private psychological evaluation report dated July 2016 in support of his claim. The examiner interviewed the Veteran and reviewed his medical history, and determined that the Veteran has permanently and total occupational impairment due to his service-connected psychotic disorder. Notably, however, the July 2016 examiner did not specifically address whether the Veteran was unemployable prior to March 12, 2014 as a result of his psychological disabilities. The Board notes that there is some conflicting evidence of record as to whether the Veteran's service-connected disabilities rendered him unemployable prior to March 12, 2014. However, the "applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner." Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Moreover, whether a veteran could perform the physical and mental acts required by employment at a given time is an issue about which a lay person may provide competent evidence. Id. at 1354 (Fed. Cir. 2013) ("neither the statute nor the relevant regulations require the combined effect [of disabilities] to be assessed by a medical expert"). The evidence demonstrates that the Veteran had considerable occupational impairment due to his service-connected psychotic disorder, NOS, and pes planus from September 12, 2009 to March 12, 2014. Moreover, he does not have a high school diploma or GED, was previously employed as a general laborer, and has been unable to maintain employment since 2008 due to the impact of his service connected disabilities. The evidence is thus at least evenly balanced as to whether the Veteran's service connected disabilities rendered him unemployable from September 12, 2009 to March 12, 2014. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to a TDIU for this time period is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. ORDER Entitlement to service connection for PTSD is denied. An initial disability rating of 70 percent, but no higher, for psychotic disorder, NOS, is granted for the entire appeal period, subject to controlling regulations governing the payment of monetary awards. Entitlement to a TDIU from September 12, 2009 to March 12, 2014 is granted, subject to controlling regulations governing the payment of monetary awards. ____________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs