Citation Nr: 1647457 Decision Date: 12/21/16 Archive Date: 12/30/16 DOCKET NO. 10-41 916 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for posttraumatic stress disorder (PTSD) prior to January 12, 2009, and in excess of 30 percent thereafter. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD M. Hendricks, Associate Counsel INTRODUCTION The Veteran had active duty service from July 1968 to July 1971, to include service in the Republic of Vietnam from July 1969 to June 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) which denied entitlement to service connection for PTSD. The Veteran appealed this denial, and entitlement to service connection for PTSD was awarded in a December 2008 rating decision with 10 percent disability rating being awarded at that time. The Veteran appealed the rating assigned, and in June 2009, a rating decision was issued which increased the disability rating to 30 percent as of January 12, 2009. The Veteran continued to appeal the rating assigned. A December 2009 rating decision denied entitlement to TDIU and the Veteran timely appealed this decision. In June 2010, the Veteran and his spouse testified at a personal hearing before a Decision Review Officer (DRO). A transcript of that hearing is of record. The Veteran failed to report for his Board hearing that was scheduled for October 2016 and has not requested that a new hearing be scheduled. Therefore, the Board considers the Veteran's hearing request to be withdrawn. FINDINGS OF FACT 1. Throughout the appeal period, the symptoms associated with the Veteran's PTSD resulted in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. The Veteran's service connected disability (PTSD) has not rendered him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for establishing a 30 percent evaluation, but no higher, throughout the appeal period for the Veteran's PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2015). 2. The criteria for establishing entitlement to TDIU have not been met in this case. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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 and 3.326(a) (2015). VA provided adequate notice in letters sent to the Veteran in September 2007, February 2009 and October 2009. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service, VA, and private treatment records are associated with the claims file. VA provided adequate examinations in January 2008, June 2009, July 2010, and July 2015, as discussed below. There is no indication of additional existing evidence that is necessary for a fair adjudication of the claim that is the subject of this appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2015); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2015); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2015); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2015). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran was awarded service connection for PTSD from July 31, 2008. The Veteran's PTSD has been evaluated as 10 percent disabling from July 31, 2008 to January 11, 2009, and 30 percent disabling for the period beginning January 12, 2009. Those evaluations are assigned under Diagnostic Code 9411. Under Diagnostic Code 9411, which is governed by a General Rating Formula for Mental Disorders, a 10 percent evaluation is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, Diagnostic Code 9411 (2015). A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (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; mild memory loss (such as forgetting names, directions, recent events). See Id. A 50 percent rating is warranted 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. See Id. A 70 percent rating is warranted 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. See Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; 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. See Id. The Board is mindful that the lists of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). One factor for consideration in evaluating mental disorders is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF score of 61 to 70 indicates some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). 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). 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 major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). During his June 2010 hearing, the Veteran reported that he sometimes sees ghosts, such as a body lying on the ground that appears to be a younger male. He reported that he has visions of Eskimo, a Corpsman who passed away during his service in Vietnam, and described that he hears Eskimo speak to him, mostly in his head, and that it is a "calming spirit." The Veteran also indicated that he has a hard time trusting people in general, and gets on edge. He reported that he was following his wife around in 2009 due to trust issues. Additionally, he reported that he showed up at the urgent care unit once due to a flashback, but that the doctor talked him out of it. Further, the Veteran reported strained relationships with his son and other family members, attributing this to a fear of getting close to people as they could be taken from him. The Veteran reported that he is depressed sometimes, and that it "comes and goes." Lastly, the Veteran reported that he was working in the VA greenhouse at that time. The Veteran's wife submitted a June 2010 affidavit in support of the Veteran's increased rating claim. She stated that the Veteran does not spend time with people at all, he isolates himself, and sometimes he will imagine things. She reported that the Veteran will see a shadow moving across the living room or a person in the window, and this has happened at night usually once a month, maybe once every two months. She stated the Veteran does not trust anyone, does not visit his family, and shuts himself in the house. Further, she stated the Veteran is continuously depressed, not motivated to do anything, is irritable and will snap at her over things that are nothing, and does not keep himself clean without prodding. Finally, she stated that the Veteran has panic attacks, anxiety attacks, is depressed every moment of everyday, is irritable, and always sluggish, sad, and unproductive. Turning to the clinical evidence, the Veteran underwent a VA examination in January 2008. The Veteran reported having close and loving relationships with his wife, in-laws, children, and grandchildren, and had many friends. The Veteran also reported he had no history of suicide attempts. He reported occasionally experiencing distressing memories of his Vietnam. On examination, the examiner noted the Veteran was able to independently care for his personal hygiene and other activities of daily living, made good eye contact, established personable rapport, had good memory and concentration, completed Serial Sevens without errors, his speech was of normal rate, fluency, and articulation, and the Veteran reported no hallucinations, no significant anxiety, anger, or depression, and no panic attacks or panic-like symptoms. The examiner concluded that overall, the Veteran did not seem to be suffering from PTSD; while he did report a stressor that met DSM-IV stressor criteria, he did not report any psychological symptoms that met DSM-IV symptom criteria. The examiner stated the Veteran did suffer from a mild mental disorder that was independently responsible for some mild psychosocial dysfunction, which was diagnosed as an adjustment disorder, not otherwise specified. Subsequent to the January 2008 VA examination, VA Vocational Rehabilitation notes from early July 2008 showed the Veteran appearing to be in a "very good frame of mind," including getting along well with his coworkers and being able to carry out his work duties with no problems. Beginning on July 31, 2008, VA psychiatric treatment notes showed the Veteran with a mildly dysphoric and anxious mood with slowed speech. The Veteran reported guilt and shame due to his stressor in the Vietnam War and reported re-experiencing symptoms including recurrent and intrusive recollections and dreams, and physiological reactivity upon exposure to cues. Further, the Veteran reported occasional feelings of detachment and estrangement from others, particularly those who had not experienced combat, and problems concentrating at times due to increased arousal and exaggerated startle response. The Veteran was diagnosed with PTSD. Following this diagnosis, VA treatment records showed a continuation of symptoms. Although the Veteran's PTSD symptoms occurred with mild intensity and frequency and duration was only brief, in early August 2008, the Veteran reported he had flashbacks 10-20 days per month. Further, in October 2008, the Veteran reported he had a flashback experience the prior weekend and awoke in a panic and cold sweat. Additionally, at another session in October 2008, the Veteran's depressive symptoms, to include guilt, helplessness, and intermittent hopelessness, were resolving following the Veteran disclosing recent financial deception to his family. The Veteran continued to report occasional flashbacks of Vietnam, but his physician stated these symptoms "currently continued to present as sub threshold." In November 2008, the Veteran reported that his mood was only mildly dysphoric, and that he had nightmares of past trauma only intermittently and with mild frequency. In December 2008, the Veteran stated he was suffering with depression and had a significant event several weeks ago that caused him to entertain the thought of suicide, but his family rallied around him and demonstrated their love for him and he no longer was entertaining the idea. In late January 2009, the Veteran's speech was tangential and circumstantial, but he denied worsening mood symptoms, reported no suicidal or homicidal ideations, and reported improved relationships with his family. It was noted that the Veteran's appearance evidenced only fair grooming, and that the Veteran was usually shaven and well groomed. In February 2009, the Veteran's examination showed his thoughts were tangential and perseverative at times, and he noted seeing a "figure" around three times per week that he believed was a ghost from when he was in active duty; however, the Veteran also reported he was "less concerned about these symptoms." In June 2009, the Veteran discussed nightmares and events that triggered his nightmares, but was able to share past traumas with low emotionality. The Veteran shared that he had a suicidal ideation earlier in the year, but denied any recent thoughts. A second VA examination was performed in June 2009. The Veteran reported he had some hallucinations, noting he saw something at the end of his bed two to three weeks ago for three to four minutes at a time. He reported he had nightmares twice every 2 weeks. The Veteran stated he had anxiety, and reported he had depressed mood at least 25 out of the past 30 days. He reported low energy, difficulty concentrating, but stated he was able to finish things at work. The Veteran also stated his distress was about feeling helpless as related to his multiple sclerosis (MS) , and wondering if he was a burden to his family. The Veteran also reported he was working at the VA greenhouse 35 hours a week, and his job was going well with no social problems. The Veteran reported that he had not gone to work for 4 days over the last year due to his depression, but attributed more of his time off from work to his physical problems. The Veteran reported he felt suicidal approximately one year ago, but denied any current suicidal thoughts. The VA examiner stated the Veteran appeared to be engaged in routine responsibilities of self-care in terms of his personal hygiene, his family functioning appeared to be good, and he still had some recreational and leisure pursuits. On examination, the Veteran was able to follow directions, his attention and concentration were good, as well as his eye contact. He denied any current suicidal or homicidal thoughts, appeared to have good personal hygiene, and his speech was logical for the most part. Additionally, the Veteran reported only having three panic attacks a year, and did not indicate any recently. However, the Veteran reported having some auditory hallucinations, about every 5 days, though the examiner noted he had previously reported visual hallucinations three times a week. Based on the overall examination, the examiner gave the Veteran a GAF score of 61, indicating mild symptoms. The examiner stated there appeared to be only mild impact on his level of functioning in that he is able to work 35 hours a week, has good social contacts, and nightmares are relatively infrequent, occurring twice every 2 weeks. The examiner concluded that the PTSD symptoms were transient and mild, and decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. In July 2009, the Veteran was seen for an unscheduled visit after presenting in urgent care in acute distress due to a reported flashback experience, which was triggered by speaking with a fellow Veteran about a recent death which brought about recollections of past traumatic loss. However, the Veteran reported he benefited from his visit with the psychiatrist, and his examination showed normal speech, only a mildly anxious and dysphoric mood, no evidence of delusions or hallucinations, and no suicidal ideations. In August 2009, the Veteran displayed no significant symptoms of anxiety or dysphoria; his mood was described as euthymic; his eye contact was improved; his speech was normal; his affect was full and bright; and there was no evidence of delusions, hallucinations, or suicidal ideations. In September 2009, a VA examination showed the Veteran was lethargic with psychomotor retardation evident, although the examiner concluded these symptoms were likely due to his multiple sclerosis. The Veteran's speech was normal, mood was only mildly dysphoric, there was no evidence of delusions or hallucinations, and he denied any suicidal ideations. In February 2010, the Veteran continued to report emotional discomfort related to re-experiencing PTSD symptoms, but evidenced less avoidant and hyperarousal symptoms. The Veteran's primary experiences reported included those related to traumatic loss and believing that spirits of those past were visiting him; however, he denied that this perception and experience caused any distress. A comprehensive VA psychiatric evaluation was performed in June 2010. The examiner stated that although the Veteran had a history of PTSD symptoms, more recently his problems had been more related to mood, cognitive, and behavioral symptoms secondary to MS. The Veteran reported no suicidal ideations presently, but occasional in the past. Examination showed good appearance and grooming, retardation of psychomotor behavior related to MS, full affect, mildly dysphoric mood, thought content about past losses, thought process logical and spontaneous, concentration only mildly impaired at times, and good attention, comprehension, and judgment. The examiner noted some issues with insight, stating that the Veteran evidenced much denial about limitations related to MS and blamed problems on combat related experiences despite clear evidence that mood, cognitive, and behavioral symptoms were mostly due to MS. The Veteran reported no suicidal ideations. The examiner stated the Veteran's PTSD symptoms occurred with mild intensity and frequency, and duration was brief. In June 2010, the Veteran noted he avoided family outings in the past, but reported it was due to him being shy about his MS symptoms. Examination showed the Veteran had appropriate appearance; made good eye contact; was deceptive with spouse about work ending although cooperative and non-confrontational; had normal speech; was mildly dysphoric, had full affect; had no evidence of delusions or hallucinations; and no suicidal or homicidal ideations. A third VA examination was performed in July 2010. The VA examiner considered the affidavit submitted by the Veteran's wife regarding his PTSD symptoms and the entire claims file. During the examination, the Veteran reported he had heard a woman's voice for the past 2-3 months that he talked back to; he reported he hears this voice 2-3 times weekly. He stated he also sometimes heard a loud hussle of voices like he heard when there was going to be a rocket attack and there were injured coming in. He reported this occurred once a month when he was sitting around or at bedtime. On examination, the Veteran was clean, neatly groomed, cooperative, and friendly, had a normal affect and mood, and had only mild disturbance in attention. His thought process and thought content were unremarkable, and his judgment was good. The Veteran reported his last panic attack was over a year ago. There were no homicidal or suicidal thoughts. The examiner noted that while hearing voices and occasional visual hallucinations had been noted as persistent in the record, the Veteran's behaviors did not appear to be influenced by hallucinations. The examiner concluded the Veteran did appear to meet the criteria for PTSD, including re-experiencing, avoidance and hyperarousal symptoms, with sleep disturbance well-controlled with medications, mild irritability, and some watchfulness noted. She concluded that while the Veteran's PTSD caused occasional decrease in work efficiency and there were intermittent periods of inability to perform occupational tasks, the Veteran generally had satisfactory functioning. In August 2010, the Veteran reported he had less difficulty related to the sustained effects of trauma in part due to more pressing issues related to MS illness progression. VA Vocational Rehabilitation notes from May to September 2010 showed the Veteran doing well. The Veteran was working between three and six hours a day in the greenhouse with his peers, planting baskets of flowers and socializing with the staff. Although the notes indicated a few instances of reported depression, the Veteran was mostly consistently alert, oriented, appeared in no distress, had good hygiene and grooming, and stated he was feeling well and denied any psychosocial or medical issues. His mood was calm and his affect congruent, and he denied any suicidal ideations. An August 2010 opinion by the Veteran's VA vocational rehabilitation counselor indicated that the Veteran was diagnosed with PTSD and has a mistrust and estrangement from people, does not like being in crowds, has intrusive thoughts, and depressive episodes. He stated the Veteran's PTSD and MS were so severe that employment was not feasible. The evidence showed little psychiatric treatment from 2011-2012. Although the Veteran reported two instances of "fleeting thoughts of suicide" in 2011, the examiners noted the Veteran did not have any action plan or intent to harm self-expressed at the evaluations. Notes also showed the Veteran was successfully working at an IT position at the information desk in a VA facility. In January 2013, the Veteran reported more anxiety issues, that he was getting more easily startled, that loud noises bothered him, he was getting more nervous, and was short-tempered. He also reported getting some nightmares, but denied any suicidal ideations. The Veteran's examination was normal at this time. In May 2013, the Veteran reported he still thought about military times, and that he felt helpless and guilty when he talked about his traumatic experiences in Vietnam. He reported some flashbacks and anxiety attacks, but stated his new anxiety medications helped him. On examination, he was pleasant, cooperative, had normal speech, had an anxious mood, but denied any delusions, auditory or visual hallucinations, or any suicidal ideations. Subsequent treatment notes from 2013 showed the Veteran reported to his IT employment at the information desk of a VA facility. His hygiene was good, his mood was cheerful, and his attitude was friendly. In February 2014, the Veteran presented for a visit with his VA neurologist to discuss a few episodes of hallucinations. The Veteran stated that he heard voices, like a lady talking in a Vietnamese accent, but when he turned around he did not see anyone. He reported having similar experiences a "few" times. In March 2014, the Veteran again stated he had hallucinations as reported earlier, typically seeing people standing in places when actually he knew that there was nobody there. However, the physician stated these visual hallucinations were due to the Veteran being on Prednisone for his MS on a regular basis. In April 2014, the Veteran's examination showed he was pleasant and cooperative, had normal speech, an anxious mood, and denied any delusions, hallucinations at present, or suicidal ideations. A fourth VA examination was conducted in May 2015. Examination showed the Veteran had good eye contact, normal psychomotor behavior, a cooperative attitude toward the examiner, a normal mood and broad affect, intact attention and concentration, normal speech, logical and sequential thought process, and fair judgment and insight. The Veteran reported seeing people he knew in the military at times, but also stated it did not disturb him, and the people would be exactly as he recalled them in the past. Additionally, the Veteran stated he had panic attacks in the distant past, but none since approximately 2010. There were no significant issues with sleep noted, the Veteran was able to maintain hygiene, and he denied any suicidal ideations. The examiner specifically stated that the Veteran's symptoms of mild neurocognitive disorder, to include trouble finding right words and memory loss, were attributed solely to the Veteran's MS. He summarized the Veteran's PTSD as an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The VA treatments notes from 2015 and 2016 showed continuously mild and sporadic symptoms of the Veteran's PTSD. The Veteran called and reported having hallucinations in February 2015, but these were again attributed to be secondary to the Veteran's use of Prednisone for his MS symptoms. In August 2015, the Veteran stated he was having nightmares only about once every 2 weeks, and reported his mood was "okay." In September 2015, the Veteran reported he experienced memories of his experiences in Vietnam daily, but denied feeling depressed and stated he was maintaining good relationships with his wife and grandchildren. He stated that when he had thoughts of Vietnam, he focused on the good parts. His examination was within normal limits, and he denied suicidal ideations. The Board has also reviewed the Veteran's VA treatment records through 2016 that have been associated with the claims file. Those treatment records are generally similar in substance with the second, third, and fourth VA examinations and the treatment records that are discussed above. Based on the foregoing evidence, the Board finds that a 30 percent evaluation, but not higher, is warranted throughout the appeal period. The Board notes that the basis of the award of 30 percent is the June 2009 VA examination; however, in review of the noted symptoms in that examination and the evidence of record prior to that time, particularly the VA treatment records and the July 2008 examination report, the Board cannot find any discernable difference in symptomatology described during those periods of time. Specifically, the Veteran was reporting a dysphoric and anxious mood, slowed speech, guilt and shame, recurrent and intrusive recollections and dreams of Vietnam experiences, occasional feelings of detachment or estrangement from others, symptoms of increased arousal, some problems concentrating, and an overall occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks was noted. Additionally, the Board notes that subsequent VA examinations and treatment records remain consistent with a 30 percent rating evaluation for the Veteran's PTSD. For instance, there is no evidence of a flattened affect or circumstantial, circumlocutory, or stereotyped speech; in fact, the Veteran consistently presented with a full affect and normal speech during examinations and treatment. Further, while the Veteran did report occasional panic attacks, he stated at his VA examination in May 2015 that he had no panic attacks since approximately 2010. Likewise, while the Veteran does show some impairment of short-term and long-term memory throughout the appeal period, the VA examiner in 2015 specifically stated this was solely attributed to his MS. Additionally, there is no evidence of impaired judgment, impaired abstract thinking, or difficulty in establishing and maintaining effective work and social relationships. The Veteran is shown to consistently have fair to good judgment Further, as noted above, the Veteran was able to work 35 hours in the VA greenhouse in 2010, and was able to work in IT employment at the information desk of a VA facility from 2011-2013. During these periods of employment, VA treatment records consistently showed the Veteran's hygiene, mood, attitude, and socialization were good. Although the evidence does show the Veteran had to stop working at the information desk in 2014, this was due to his physical symptoms of MS, which required him to be hospitalized on and off from 2013 to 2016. The Board acknowledges that the evidence demonstrates the Veteran experienced occasional flashbacks and some auditory and visual hallucinations during the appeal period. However, the record shows these were relatively infrequent, and he stated on several occasions that these flashbacks and hallucinations did not cause him distress. Additionally, the VA examiner in 2010 noted the Veteran's occasional hearing of voices and experiencing visual hallucinations did not appear to influence him. Further, the Veteran's physician stated twice in 2014 that the Veteran's visual hallucinations were likely related to his use of Prednisone, which he was using to treat his MS. Lastly, while the Veteran reported having "fleeting" thoughts of suicide in 2008, 2009, and 2011, as noted above, there is no evidence in the record of any action plan or intent to harm himself. Further, the Veteran reported suicidal thoughts very infrequently; as noted, the Veteran consistently denied any suicidal thoughts in the majority of the treatment records in the file. For these reasons, the Board must find that evaluations higher than 30 percent are not warranted for the Veteran's PTSD. Accordingly, a 30 percent evaluation, but no higher, for the Veteran's PTSD throughout the appeal period is warranted. See 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. Additionally, the Board must contemplate whether the case should be referred for an extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1) (2015). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. In this case, VA has carefully compared the level of severity and symptomatology of the Veteran's psychiatric disability with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which he is currently evaluated. In this regard, the totality and the severity of the Veteran's occupational and social functioning are contemplated by the Rating Schedule, including a wide variety of psychiatric symptoms and types of impairment. For these reasons, as the rating schedule is adequate to evaluate the psychiatric disability, referral for extraschedular consideration is not in order. Also considered by the Board is whether the collective effect of his other service connected disabilities warrant referral for extra-schedular consideration. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). However, PTSD is the Veteran's only service-connected disability. Thus, further consideration of this issue is not warranted. Turning to the Veteran's TDIU claim, VA will grant TDIU when the evidence shows that the Veteran is precluded, by a reason of service-connected disabilities, from obtaining and maintain any form of gainful employment consistent with education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2015). There are two regulatory subsections that allow for a TDIU. The first, called a "schedular TDIU," is found at 38 C.F.R. § 4.16(a) and requires that certain disability rating percentages be in place. Either the Board or the AOJ can grant a schedular TDIU in the first instance. The second, called an "extraschedular TDIU," is found at 38 C.F.R. § 4.16(b). It does not have the percentage requirement but cannot be granted by the Board or the AOJ in the first instance, it must be submitted to VA's Director, Compensation Service in the first instance. 3 8 C.F.R. § 4.16(b). The schedular TDIU subsection provides that a total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: 1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. In this case, as noted above, the Veteran's PTSD is evaluated as 30 percent disabling, and the Veteran does not have any other service-connected disabilities. Thus, he does not meet the scheduler criteria for an assignment of TDIU in this case. See 38 C.F.R. § 4.16(a). However, regardless of whether the Veteran meets the schedular criteria, the Board has determined that referral for extra-schedular consideration for TDIU under 38 C.F.R. § 4.16(b) is also not appropriate in this case. The reasoning is as follows. While it is clear that the Veteran has some occupational and functional impairment as a result of his psychiatric disability, the evidence does not support that the Veteran's PTSD precludes him from securing and following a substantial gainful employment. The Board so finds as the Veteran is shown to be working from 2010-2013 for VA, first in a greenhouse and then at an information desk of a VA facility. He was shown to be working nearly 40 hours throughout that period, and did not have any significant problems interacting with other people in those positions. Furthermore, the record demonstrated that he stopped due to his physical conditions of his non-service connected MS, and not due to his psychiatric symptoms. Moreover, all four VA examiners stated that the Veteran's PTSD would only cause at most occasional decreases in his ability to perform occupational tasks. Consequently, the Board finds that the evidence of record does not demonstrate that the Veteran is unable to secure and follow a substantially gainful employment as a result of his service-connected disabilities at this time. Therefore, a referral for extraschedular consideration of TDIU under 38 C.F.R. § 4.16(b) is not appropriate in this case. See 38 C.F.R. §§ 3.102, 4.16(b). 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 in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER A 30 percent evaluation, but no higher, throughout the appeal period for the Veteran's PTSD is granted. Entitlement to TDIU is denied. ____________________________________________ M. HYLAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs