Citation Nr: 1752474 Decision Date: 11/15/17 Archive Date: 11/22/17 DOCKET NO. 11-20 462 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial rating greater than 70 percent prior to May 19, 2014, for an acquired psychiatric disorder, to include depression, generalized anxiety disorder, and delusional disorder. 2. Entitlement to an initial rating greater than 30 percent from May 19, 2014, for an acquired psychiatric disorder, to include depression, generalized anxiety disorder, and delusional disorder. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Molly Steinkemper, Attorney at Law ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service from May 1980 to July 1981 and received an honorable hardship discharge. This matter comes to the Board of Veterans' Appeals (Board) on appeal from September 2011 and October 2014 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The Board remanded the TDIU claim in April 2014 and October 2014, as the claim was inextricably intertwined with another remanded claim. In addition, the Board remanded both of the above-listed issues in October 2015 and April 2016. The matter again is before the Board. This appeal was processed using the Veteran's Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. Accordingly, any future consideration of the case should take into consideration the existence of these electronic records. FINDINGS OF FACT 1. Prior to May 19, 2014, the Veteran's service-connected acquired psychiatric disorder was manifested by symptoms such as confused and disorganized thinking, sadness, intermittent tearfulness, sleep problems, feelings of guilt, concentration problems, psychomotor slowing, anxiety with nervousness, concern about leaving the home, and difficulty making decisions, all resulting in less than total social and occupational impairment. 2. From May 19, 2014, the Veteran's service-connected acquired psychiatric disorder is manifested by symptoms such as difficulty focusing, chronic sleep impairment, depressed mood, tearfulness, and anxiety, resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 3. The Veteran's service-connected disabilities do not preclude her from securing and following a substantially gainful occupation. CONCLUSIONS OF LAW 1. Prior to May 19, 2014, the criteria for a disability rating greater than 70 percent for an acquired psychiatric disorder, to include depression, generalized anxiety disorder, and delusional disorder, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9434 (2016). 2. From May 19, 2014, the criteria for a disability rating greater than 30 percent for an acquired psychiatric disorder, to include depression, generalized anxiety disorder, and delusional disorder, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, DC 9434 (2016). 3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions. 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) (2016). VA's duty to notify was satisfied by letters to the Veteran in March 2011, April 2011, July 2011, and April 2016. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA treatment records have been associated with the electronic claims file. Records from the Social Security Administration (SSA) also have been associated with the electronic claims file. The Board acknowledges the Veteran's July 2016 statement indicating, "I have a pending Social Security Administration Law Judge hearing for my claim for disability Social Security. I request you obtain the results of this hearing and apply the results towards my TDIU claim." In April 2016, the Board remanded the claim, in part, due to a September 2015 VA Form 9 statement from the Veteran that the SSA claim was "currently on appeal and pending an Administrative Law Judge hearing." The AOJ subsequently obtained the Veteran's SSA records and SSA indicated that no additional records had been added to the file since the previous decision, which previously had been provided to VA. The Veteran has not indicated that a SSA hearing occurred between the time of the AOJ's requests for SSA records and her July 2016 statement, given that she had made essentially the same statement prior to the most recent request for SSA records. Thus, there is no indication that additional relevant SSA records are outstanding. Private records have been associated with the claims file, to the extent possible. The Veteran has at no time otherwise referenced outstanding records that she wanted VA to obtain or that she felt were relevant to the claims. For increased rating claims, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2016). The RO provided the Veteran multiple appropriate examinations, most recently in June 2016. The examiners conducted the appropriate diagnostic tests and studies and noted the Veteran's assertions. As such, the Board finds the examination reports and opinions to be thorough, complete, and sufficient upon which to base a decision with respect to the Veteran's claims. 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). Based on the April 2016 letter to the Veteran, the association of VA treatment records, the association of records from SSA, the June 2016 VA examination, and the subsequent readjudication of the claims, the Board finds that there has been substantial compliance with its prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Relevant Factual History In a June 2010 letter, the Veteran's private physician indicated that she could not serve on jury duty. The Veteran had diagnoses of PTSD and generalized anxiety, which historically had been difficult to control. The physician believed that serving on jury duty would exacerbate those symptoms and the Veteran should be excused from service or accommodations made to manage her social anxiety. A May 2011 VA treatment record noted that the Veteran's hearing problems forced her to turn up the volume on the television and that she had to have people repeat themselves. The Veteran was afforded a VA audio examination in May 2011. The Veteran reported some balance problems when rising from a seated or lying position. She also described recurrent tinnitus. The noted occupational problems due to her hearing loss were trouble hearing people when behind them. The Veteran was afforded a VA mental health examination in May 2011. The examiner noted review of the claims file and medical records. The Veteran's present symptoms were sadness and intermittent tearfulness. She slept 3 to 4 hours per night. Her interests included reading and gardening. The Veteran's husband indicated that she expressed feelings of guilt about not being able to take better care of her children. The Veteran had problems with concentration and was described as "losing focus." There was psychomotor slowing, but no suicidal ideation. The Veteran had anxiety with nervousness and was careful about leaving home. She was afraid to make decisions. On examination, the Veteran was clean and appropriately dressed. Speech was normal. Affect was constricted and her mood was anxious and dysphoric. She was unable to do serial 7s or spell a word forward and backward. She was fully oriented and thought content was unremarkable. The Veteran denied delusions and had appropriate judgment and insight. She denied hallucination, inappropriate behavior, obsessive behavior, or homicidal thoughts. Impulse control was good and there were no episodes of violence. She could maintain personal hygiene and had no problems with activities of daily living. Her memory was normal. The Veteran's thinking appeared confused and disorganized and she had difficulty making decisions regarding her teenage children. The Veteran's prior occupation was in clerical work and owning an auto repair shop and rental properties, but she had retired in 2000. She believed that mentally she was unable to work. Her most recent job had been at Walmart where her mental health problems had affected her work, but she ultimately stopped working due to physical problems. The examiner noted that the Veteran had problems with hearing acuity and tinnitus, but did not require hearing aids and was able to hear effectively during the examination. She had problems following the conversation and understanding what was being asked. The Veteran underwent another VA mental health examination on May 19, 2014. The examiner noted that the Veteran had occupational and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during period of significant stress or that her symptoms were controlled by medication. The examiner noted review of the claims file. The Veteran had been married to her current husband for 12 years. It was her sixth marriage. The Veteran had three grown children and she and her husband had adopted her 5-year old grandson. She had 3 other grandchildren and her husband had 4 grandchildren of his own. The Veteran had some contact with her extended family. She denied social activities except with her husband, as she had problems with other people unless they were people she chose to be around. The Veteran's husband indicated that home was her only sanctuary. The Veteran denied any educational courses since the last VA examination, was not currently employed, and had not worked since the last examination. The Veteran spent her time caring for her adopted 5-year old grandson, doing housework, grocery shopping, going to the bank, and other activities. She denied any hobbies, but indicated that she kept busy and did state that she read books. On examination, the Veteran was appropriately dressed and groomed, fully oriented, had intact attention and concentration, had a frustrated and lonely mood, intact insight and judgment, had nightmares and other sleep problems, and had intact memory. She reported an exaggerated startle response, hypervigilance, difficulty with crowds, and avoidance behavior. The Veteran was capable of managing her financial affairs. The Veteran, however, stated that she was not functioning. Records from SSA indicated that the Veteran could not work due to PTSD, a bad back, a bilateral foot disability, bilateral hearing loss, high blood pressure, hypothyroidism, arthritis, and Meniere's disease. In a May 2015 determination, an SSA disability adjudicator found that the problems were not disabling through December 2003. The Veteran was afforded another VA mental health examination in June 2016. The examiner noted review of the claims file and attributed the Veteran's symptoms of difficulty focusing and chronic sleep impairment to her major depressive disorder. Her personality disorder resulted in suspiciousness, a pattern of unstable relationships (does not like going around people because she felt humiliated around them and like she could not trust them), difficulty establishing and maintaining effective work and social relationships, disturbances in motivation and mood, fears of abandonment, paranoia, and inappropriate expressions of anger. Both disorders resulted in symptoms of depressed mood, tearfulness, and anxiety. The Veteran's psychiatric disorders resulted in occupational and social impairment with reduced reliability and productivity. The examiner indicated that the overwhelming majority of the Veteran's current occupational and social impairment was related to her personality disorder that was resulting in her reduced reliability and productivity. Her major depressive disorder likely resulted in occasional decreases in functioning, although generally functioning satisfactorily. The Veteran currently was living with her husband and son. She had been married for 14 years and described their relationship as "alright." The Veteran had 4 children and had a good relationship with them. Her current hobbies involved doing things around the house and reading. Her social support came from her husband and children. The Veteran had not worked since 2001 as a stocker at Walmart. The Veteran denied any suicide attempts or thoughts of harming herself or others. Her symptoms included nightmares, tearfulness, daily depression, acute anxiety that did not reach the diagnostic level of panic attacks, a pattern of unstable relationships, fears of abandonment, paranoia, and difficulty focusing. Her difficulty focusing, nervousness, and depression made working difficult. She also reported inappropriate expressions of anger about 12 times per month. Additional symptoms included suspiciousness, and disturbances of motivation and mood. On evaluation, the Veteran was appropriately dressed and groomed, had logical speech, was cooperative but had difficulty providing direct answers and specific examples of her symptoms, was fully oriented, had good concentration and attention, had good judgment and insight, and had an upset and frustrated mood. The examiner indicated that the symptoms attributable to the major depression fell in the moderate range and the overwhelming majority of the Veteran's occupational and social impairment were due to the nonservice-connected personality disorder. The problems with social interaction were solely attributable to the personality disorder and would likely result in moderate to severe occupational and social impairment due to her irritability and difficulty getting along with others. Her depressive symptoms included difficulty concentrating, anxiety and depression that would only result in transient occupational and social impairment. The personality disorder and depression were etiologically distinct and unrelated. Finally, the Veteran's personality disorder was a longstanding characterological issue that was unrelated to her service. Ratings Disability ratings are assigned, under a schedule for rating disabilities, based on a comparison of the symptoms found to the criteria in the rating schedule. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2016). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2016). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2016). VA must consider whether the Veteran is entitled to "staged" ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. As discussed above, currently the Veteran's disability rating is 70 percent for her service-connected major depressive disorder. The Veteran claims the rating does not accurately depict the severity of her condition. The General Rating Formula for Mental Disorders provides, in pertinent part: 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) . . . . . . . . 30 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 . . . . . . . . . . . . . . . . . . . . . . . 50 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or name . . . . . . . . . . . . . . . . . . . . . . . . . 100 38 C.F.R. § 4.130, DC 9434 (2016). When determining the appropriate disability evaluation under the general rating formula, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). 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. Nevertheless, as 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 rating under the general rating formula by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Id at 117-18. Additionally, a Global Assessment of Functioning (GAF) score is often used by treating examiners to reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996). A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). The Board recognizes that GAF scores are not utilized in the DSM-5 (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders). Prior to May 19, 2014 After a careful review of the record and for the reasons and bases expressed immediately below, the Board finds that the Veteran's demonstrated acquired psychiatric disorder symptomatology does not warrant an evaluation greater than the currently assigned 70 percent rating prior to May 19, 2014. A rating greater than 70 percent is not appropriate for this time period because the Veteran does not have total social and occupational impairment. Although the Veteran clearly had a serious disability during this timeframe the evidence does not show that there is total occupational and social impairment. As to occupational functioning, the Veteran was not working during this time period. That said, the Veteran reported that she left her last job at Walmart in 2001 due to physical problems with the job, rather than due to her acquired psychiatric disorder (although her mental health symptoms did affect her ability to perform her job). The evidence does not demonstrate that had the nonservice-connected physical problems not caused her to leave employment that she would not have been working at Walmart during the period prior to May 19, 2014. As to social functioning, the Board finds that the Veteran has not had total impairment of social functioning for the period prior to May 19, 2014. The Veteran was married during the entire relevant time period prior to May 19, 2014, and the couple had adopted and was raising her young grandson. She also maintained a relationship with her children and extended family. The Veteran had problems with social interaction with those not in her family, but has remained able to interact on a social level such that she was able to leave the house to shop, bank, and engage in other activities. The Board does not find the foregoing to represent total social impairment for any period prior to May 19, 2014. Thus, the Veteran did not have both total social and occupational impairment sufficient to warrant a total schedular rating at any point prior to May 19, 2014. She did have some deficiencies in several areas, but the greater weight of evidence demonstrates that her symptoms are to a degree that is contemplated by the 70 percent rating currently assigned. Again, in determining that a rating in excess of 70 percent is not warranted, the Board has considered the Veteran's complaints regardless of whether they are listed in the rating criteria, but for the reasons discussed above concludes that the Veteran's level of social and occupational impairment does not warrant a rating in excess of the currently assigned 70 percent rating for the period prior to May 19, 2014. In summary, for the reasons and bases set forth above, the Board concludes that an increased rating greater than 70 percent is not warranted for any period of time prior to May 19, 2014. From May 19, 2014 After a careful review of the record and for the reasons and bases expressed immediately below, the Board finds that the Veteran's demonstrated service-connected acquired psychiatric disorder symptomatology does not warrant an evaluation greater than the currently assigned 30 percent rating from May 19, 2014. Initially, the Board notes that from merely looking at the totality of the Veteran's mental health symptoms reported above, it would appear, at first glance, that the Veteran's condition was more than moderately disabling, as reflected by the 30 percent evaluation assigned, including a rather significant level of occupational impairment. It also shows considerable impairment in the Veteran's ability to establish and maintain effective relationships with people. However, the determinative question in this case is whether the Veteran's complaints and resulting social and occupational impairment are due to her service-connected acquired psychiatric disorders or her nonservice-connected personality disorder. In deciding this question, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the claimant's favor, thus attributing such signs and symptoms to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). In this case, the June 2016 VA examiner diagnosed a depressive disorder (for which the Veteran is service-connected) and a personality disorder (for which the Veteran is not service-connected) and specifically discussed which symptoms were attributable to which disorder. Moreover, the examiner outlined that the overwhelming majority of the Veteran's occupational and social dysfunction were attributable to the nonservice-connected personality disorder and that the service-connected psychiatric disorder did not cause significant problems with occupational or social functioning. As such, this case is distinguishable from Mittleider because the examiner clearly outlined which symptoms were attributable to which disorder and how they affected social and occupational functioning. As discussed above, the Veteran contends that she has a pending claim before SSA to determine whether she currently is unable to work. As noted, the Veteran has previously made such a contention prior to the last Board remand, but SSA subsequently indicated that no additional evidence or documents had been added to the Veteran's SSA file. Even presuming that the Veteran was found to be totally disabled by SSA, VA is required to consider SSA's findings but is not bound by their conclusions. Adjudication of VA and SSA claims are based on different laws and regulations. See, e.g., Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). The law requires VA to make an independent analysis and determination. In summary, the Board finds the June 2016 VA examiner's opinion to be the most probative evidence of record for the period from May 19, 2014, as to the nature of the Veteran's symptoms attributable to her service-connected acquired psychiatric disorders. The examiner specifically concluded that the personality disorder was unrelated to both the service-connected acquired psychiatric disorder and her active service. In context, the Board finds that such conclusions clearly contemplated both causation and aggravation as to any relationship between the personality disorder and the service-connected psychiatric disorders. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (a medical report must be read as a whole in the context of the claim and, even an opinion lacking in detail may be provided some probative value based upon the amount of information and analysis contained therein) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293-294 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)). Considering the specific rating criteria, for the period from May 19, 2014, the Veteran is not shown to have difficulty in establishing and maintaining social relationships based on her service-connected psychiatric disorder. The Veteran has maintained an extended marriage to her current husband, is raising an adopted grandson, and has a good relationship with her children. The Veteran has difficulty in occupational and social settings, but these problems have been medically attributed almost entirely to her nonservice-connected personality disorder. The record does not reflect that the Veteran had panic attacks more than once a week (as what she described as panic attacks did not meet the diagnostic criteria to be considered panic attacks, impairment of memory, impaired judgment, speech or abstract thinking, disturbances of motivation or mood, or other such problems. The Veteran has been fully oriented and any problems with thinking have been medically attributed to her nonservice-connected personality disorder. Similarly, to the extent that she experienced mood disturbances, such as irritability and anger, those symptoms also have been medically attributed to her personality disorder. Thus, from May 19, 2014, the Board concludes that the Veteran's overall level of disability more nearly approximates that consistent with a 30 percent rating. Although the Veteran experienced some symptoms that were consistent with a higher rating, namely severe occupational and social impairment and irritability issues, the most persuasive medical evidence of record attributes these symptoms to her personality disorder. Thus, in evaluating all of the evidence of record, the Board finds that from May 19, 2014, the Veteran's service-connected acquired psychiatric disorder symptoms more nearly approximated moderate social and occupational impairment, or a 30 percent disability rating. Therefore, a higher rating is not warranted for any period from May 19, 2014. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16 (2016). A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15 (2016). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more and 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). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the Veteran's background, including his employment and educational history. 38 C.F.R. §4.16(b). The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2016). In this case, the Board notes that the Veteran's service-connected disabilities include acquired psychiatric disorder, to include depression, generalized anxiety disorder, and delusional disorder, rated as 70 percent disabling prior to May 19, 2014, and as 30 percent disabling from that date; tinnitus, rated as 10 percent disabling; and bilateral hearing loss, rated as noncompensably disabling. The Veteran's combined disability rating was 70 percent prior to May 19, 2014, and 40 percent from that date. None of the exceptions contained in 38 C.F.R. § 4.16 are applicable. (The regulation addresses one or both upper extremities or one or both lower extremities, rather than a combination of all extremities. In addition, the disabilities are not of a single system.) Therefore, the Veteran's service-connected disabilities met the percentage rating standards for TDIU prior to May 19, 2014, and do not meet the percentage rating standards for TDIU from that date. 38 C.F.R. § 4.16(a). Thus, for the period prior to May 19, 2014, the Board must now consider whether the evidence reflects that the Veteran's service-connected disability rendered him unemployable. As to the period from May 19, 2014, the Board must consider whether the evidence warrants referral to the appropriate VA officials for entitlement to a total disability rating for compensation purposes based on individual unemployability on an extraschedular basis under the provisions of 38 C.F.R. §4.16(b). See Bowling, 15 Vet. App. at 1. For a Veteran to prevail on a claim for entitlement to TDIU, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough; the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Board concludes that for the period prior to May 19, 2014, that the Veteran's service-connected disabilities did not render her unemployable. In addition, the Board finds no evidence of record suggesting that the Veteran's case is outside the norm requiring extraschedular consideration for the period from May 19, 2014. In reaching these conclusions, the Board acknowledges that the Veteran has not worked since 2001. In addition, she reported that she left several jobs because she was unable to perform the duties due to her mental health problems. As discussed above, the Veteran's last job was as a stocker for Walmart and the evidence indicates that she left this position due to nonservice-connected physical problems, rather than mental health problems (although the mental health problems did have some effect on her work performance). As such, the evidence certainly suggests that the Veteran could still be employed at that position if not for the physical problems and despite her mental health symptoms. In any case, the Board acknowledges the Veteran's reports of an inability to work due to her mental health symptoms and the medical evidence supports those assertions to a significant degree. That said, the Board finds the June 2016 VA examiner's opinion of significant probative value. As discussed above, the examiner concluded that prior to and throughout the appellate time period the Veteran's difficulties with occupational functioning were primarily due to her nonservice-connected personality disorder. The examiner set forth the specific symptoms that were due to the personality disorder and which were the overwhelming cause of the Veteran's employment problems. The mental health symptoms associated with the Veteran's service-connected acquired psychiatric disorders resulted in moderate problems that would not preclude employment and likely resulted in occasional decreases in functioning, although generally functioning satisfactorily. As to the Veteran's service-connected hearing loss and tinnitus, she has not specifically alleged that these disabilities contribute to her inability to work. To the extent that her contentions can be read to include such a claim, the lay and medical evidence indicates that her greatest difficulty with her hearing is understanding individuals when their back is to them. She is able to converse with others when directly facing them, as specifically noted in the medical examinations of record. There is no evidence or contention as to how her hearing difficulties would preclude the Veteran from performing any of her prior jobs. The Board acknowledges that the Veteran's service-connected disabilities have some effect on her occupational impairment. However, the 70 percent schedular rating prior to May 19, 2014, and the 40 percent rating from that date recognize the industrial or commercial impairment resulting from her disorders. Nevertheless, for the reasons and bases set forth above, the preponderance of the evidence is against finding her service-connected disabilities (singly or in combination) are of such severity so as to preclude her participation in any form of substantially gainful employment. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to an initial rating greater than 70 percent prior to May 19, 2014, for an acquired psychiatric disorder, to include depression, generalized anxiety disorder, and delusional disorder, is denied. Entitlement to an initial rating greater than 30 percent from May 19, 2014, for an acquired psychiatric disorder, to include depression, generalized anxiety disorder, and delusional disorder, is denied. Entitlement to TDIU is denied. ______________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs