Citation Nr: 1750224 Decision Date: 11/06/17 Archive Date: 11/17/17 DOCKET NO. 10-18 454A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial higher rating for posttraumatic stress disorder (PTSD), evaluated as 30 percent disabling prior to February 16, 2016, and 50 percent disabling thereafter. 5. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to the service-connected disabilities. REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney-at-Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.N. Moats, Counsel INTRODUCTION The Veteran served on active duty from May 1969 to February 1973, to include combat service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from and October 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office located in Atlanta, Georgia, which granted service connection for PTSD and assigned a 30 percent rating. The Veteran provided testimony at a Board videoconference hearing in October 2012 before the undersigned Veterans Law Judge. In November 2014, the Board remanded this appeal for further development and the instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The case has now been returned for appellate review. By rating decision in May 2016, the RO increased the PTSD disability rating to 50 percent, effective February 16, 2016. However, where there is no clearly expressed intent to limit the appeal to entitlement to a specified disability rating, the RO and Board are required to consider entitlement to all available ratings for that condition. AB v. Brown, 6 Vet.App. 35, 39 (1993). The issue therefore remains in appellate status and has been characterized as set forth on the front page of this decision. The issues of entitlement to service connection for a respiratory disorder, diabetes mellitus and hypertension were also remanded by the Board. In a May 2016 rating decision, the RO awarded service connection for allergic rhinitis (claimed as respiratory condition), representing a full grant of the benefit sought on appeal. However, the RO continued to address this matter in a subsequent August 2016 supplemental statement of the case. Nevertheless, in a September 2016 statement, the Veteran withdrew his appeal as to the issues of entitlement to an initial compensable rating for allergic rhinitis and entitlement to service connection for diabetes mellitus and hypertension. As such, these matters are no longer before the Board. Additional evidence was submitted in August 2017 along with a waiver of RO consideration of such evidence. As such, the Board may properly consider this evidence. FINDINGS OF FACT 1. Prior to August 12, 2010, the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as intrusive thoughts, flashbacks, depressed mood, insomnia, impaired concentration, nightmares and irritability, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 2. From August 12, 2010, the Veteran's service-connected PTSD results in occupational and social impairment with reduced reliability and productivity due to such symptoms as a depressed mood, anxiety, sleep impairment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, but without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 3. For the entire appeal period, the Veteran's service-connected disabilities not render him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. Prior to August 12, 2010, the criteria for an initial rating in excess of 30 percent for PTSD had not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 3.321, Part 4, including §§ 4.7, 4.130, Diagnostic Code 9411 (2017). 2. From August 12, 2010, the criteria for a 50 percent rating, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 3.321, Part 4, including §§ 4.7, 4.130, Diagnostic Code 9411 (2017). 3. The criteria for a TDIU have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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) (2017). With respect to the Veteran's claims herein, the Veteran has not alleged that VA has not fulfilled its duty notify or assist in the development of his claims. The Board recognizes that the Veteran has reported ongoing treatment at the Vet Center since 2011 for his PTSD. In its prior November 2014, the Board directed the Agency of Original Jurisdiction (AOJ) to assist the Veteran in obtaining any outstanding medical records. Subsequently, in a January 2015 letter, the AOJ requested any relevant records. In February 2015, the Veteran, through his then representative, responded that he would submit additional evidence. However, to date, the Veteran never submitted any such records from the Vet Center or an authorization so that the AOJ could obtain such records. As such, the Board finds that the AOJ has met its duty to assist with respect to these records. The Board also recognizes that the Veteran reported receiving Social Security Administration retirement benefits at the most recent February 2016 VA examination. While VA's duty to assist generally requires that such records be obtained, VA is only required to obtain Social Security records when those records are potentially relevant to the claim on appeal. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Relevant records are those that relate to the injury for which benefits are sought and have a reasonable possibility of helping to substantiate the claim. Id. However, in the instant case, as the Veteran has clearly reported that he is receiving retirement benefits as opposed to disability benefits, any extant Social Security records do not have a reasonable probability of helping to substantiate the Veteran's claim, and are therefore not relevant to the instant claim. Golz, 590 F.3d 1317. As such, VA had no obligation to obtain any Social Security records. 38 C.F.R. § 3.159(c). II. Initial Higher Rating for PTSD The Veteran is seeking an initial higher rating for his PTSD. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As in the instant case, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Pursuant to that General Rating Formula, a 30 percent rating is assigned when there is 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). A 50 percent evaluation 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. Id. The next-higher evaluation of 70 percent 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. Id. A 100 percent evaluation 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; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit has held, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18 ; 38 C.F.R. § 4.130, Diagnostic Code 9411. Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. The Global Assessment of Functioning (GAF) Scale reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994). The GAF score is based on all of the Veteran's psychiatric impairments. A GAF Scale score of 41 to 50 indicates 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); and a GAF score between 51 and 60 is indicative of 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 coworkers). The Board notes that the newer Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5) has been released, and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. However, since much of the relevant evidence was obtained during the time period that the DSM-IV was in effect, and the DSM-5 is not applicable to claims certified to the Board before August 14, 2014, as in the instant case, the Board will still consider this information as relevant to this appeal. The Veteran filed his claim for service connection in October 2006. VA clinical records show treatment for PTSD. Importantly, a September 2005 clinical record showed that the Veteran reported progressive problems with insomnia, irritability and recurrent thoughts and dreams. He stated that while working as a bus driver, he was able to manage such symptoms, but since retirement in February 2004, he did not have enough structure to occupy his time. Follow up records continue to show reports of depressed mood, frequent irritability, trouble concentrating, persistent insomnia, recurrent nightmares and intrusive thoughts. On mental status examination, the Veteran was casually dressed. He was alert and thought processes were cogent. His behavior was appropriate. However, his affect was constricted and he was depressed and anxious. However, he denied delusions, hallucinations and suicidal and homicidal ideation. The Veteran was afforded a VA fee-based examination in April 2007. The Veteran reported not being able to sleep and constant flashbacks. The effect the symptoms have upon total daily functioning was the Veteran avoided others and would rather stay in bed. The Veteran required continuous treatment to control his PTSD and was taking psychiatric medication. However, he had not been admitted to a hospital or required any emergency room visits for his psychiatric symptoms. The Veteran had worked as a bus driver for 30 years and had good relationship with his supervisor and co-workers. He had a good relationship with his one sibling. He also had two children and he described the relationship with one as good and as fair with the other. He had major changes in his daily activities as well as social changes in that he avoided crowds. On mental status examination, orientation was within normal limits. Appearance and hygiene were appropriate. Moreover, behavior was appropriate. Affect and mood were abnormal with depressed mood that occurred as often as five times per week. Each episode lasted for three hours. The Veteran stayed home and did not get much sleep. Communication, speech, and concentration were within normal limits. Panic attacks and obsessional rituals were absent. There were signs of suspiciousness as the Veteran had a lack of trust for others. There was no delusional or hallucination history present. At the time of examination, there were no delusions or hallucinations observed. Thought processes were appropriate and judgment was not impaired. Abstract thinking and memory were within normal limits. Thoughts of death were passive as Veteran thought about being dead. Homicidal ideation was absent. The examiner found that the Veteran met the criteria for PTSD. The substance abuse diagnosis was alcohol and cannabis abuse, which were due to primary service-connected PTSD. The GAF score assigned was 50. The examiner concluded that the Veteran did not have difficulty performing activities of daily living. The examiner described the Veteran's current psychiatric impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self care and normal conversation. The above statement is supported by the following symptoms depressed mood, suspiciousness and chronic sleep impairment. He had no difficulty understanding commands. He appeared to pose no threat of persistent danger or injury to self or others. The Veteran was afforded another VA examination in March 2010. The claims file was reviewed. The Veteran reported that he had requested an increase in service connection because he could not afford his medication and primarily complained of physical problems. The Veteran did endorse irritability, intrusive memories, poor concentration, depression and avoidance symptoms. On mental status examination, the Veteran was alert and fully oriented. He was clean and well-groomed. His speech was normal in rate, tone, rhythm and volume. His thought was tangential, often veering into discussing his physical problems. He denied hallucinations and no delusions were elicited. He denied active suicidal or homicidal thoughts. His mood was depressed and his affect was irritable and somewhat constricted; however, he became less agitated after given a chance to talk about his physical problems. His insight and judgment seemed fairly good. The examiner diagnosed PTSD, chronic, and depressive disorder, not otherwise specified. A GAF of 51 was given. The Veteran continued to meet the criteria for PTSD. He also appeared to be suffering from low mood that seemed to be related to general health stressors, personal losses and financial worries. While PTSD is one of the concerns resulting in this depression, it does not appear to be the predominant issue. There, the examiner found that depression did not seem to be secondary to PTSD. The examiner continued that as with many individuals who suffer from PTSD, the Veteran may have experienced some worsening of his condition following his retirement and following the loss of his common law wife in 2006. However he was able to maintain lengthy employment with MARTA until 2004 in close contact with the public. He noted some recent difficulty in maintaining one particular job due to a combination of physical problems and irritability. Of note, however he did not seem to suffer from much irritability in the volunteer setting. The Veteran maintained a satisfying relationship with a significant other for more than ten years until her death in 2006. Some of his relationships have been strained over the years, but it seems he has been working to resolve these problems and now has fairly regular contact with his daughters. He speaks daily to his grandchildren in an effort to forestall the same kind of conflicts with them. He has friends with whom he spoke daily. The Veteran was able to attend to errands, hygiene and housekeeping as well as attend various volunteer functions, but stated that he cannot go to church because the crowds there were off putting. Overall, there seemed to be somewhat inconsistent findings regarding the Veteran's current level of functionality in some settings, he seems to be fairly well while he struggles more in others. Furthermore when discussing reasons for the loss of functionality, he often returns to his physical complaints. Thus, the examiner opined that there was occasional decrease in work efficiency or there were intermittent periods of inability to perform occupational tasks due to mental disorder signs and symptoms, but generally satisfactory functioning (routine behavior self care and conversation normal). The examiner concluded that there was no evidence in the claims file or in this interview that suggested the Veteran lacked capacity to manage his funds independently. VA clinical records document that the Veteran's GAF scores were 55 until approximately August 2009 when GAF scores of 50 were predominantly assigned. On mental status examination in May 2010, the Veteran had grooming and denied suicidal/homicidal ideations, plan or intent. However, he was anxious with restricted range of effect. He was hypervigilant and guarded, particularly at night. Thought processes were organized. His GAF score was 50. Subsequent records continue to document the same symptoms. In support of his claim, the Veteran submitted an August 12, 2010, statement from his Vet Center therapist. It noted that the Veteran reported detachment from family and friends and displayed significant patterns of isolation and withdrawal resulting in some social impairment. He continued to experience chronic sleep impairment, some incidents of depression, intrusive thoughts and irritability, which directly impact his quality of life. The examiner indicated that the Veteran also experienced mood disturbances and had difficulty establishing and maintaining relationships. The Veteran continued to meet the diagnostic criteria for PTSD. Prognosis was poor and therapy will continue on a weekly basis to assist in controlling these chronic and severe symptoms. The Veteran also submitted a November 2010 opinion from his treating VA psychiatrist. She reported that the Veteran endorsed depressed mood, hypervigilance, daily flashbacks, recurrent nightmares, anhedonia, lack of interest in activities/hobbies, insomnia, social isolation and unprovoked irritability. His symptoms worsened around October/November on an annual basis. The examiner continued that the Veteran was unable to maintain effective relationships. He had a close female friend who passed away in 2006, and was essentially estranged from his adult children. He had been prescribed paroxetine and prazosin for his PTSD, depression and anxiety symptoms. However, medications have helped little to decrease his anxiety and irritability. The examiner concluded that despite active and intensive treatment, the Veteran's symptoms were severe and chronic. The record also includes a July 2012 private Vocational Assessment. It was noted that the Veteran was a bus driver form August 1973 to April 2004 and a bus driver instructor from January 2007 to January 2009 when he left the labor market due to behavioral and emotional difficulties from his PTSD. The examiner reported difficulties with mood disturbances, depression, irritability, difficulties with anger management, difficulties maintaining relationships, poor concentration, flashbacks, sleep problems and frequent nightmares. The examiner observes that bus driver is an occupation that generally allows an individual to work in a socially isolated basis with limited contact with coworkers or peers and does not require interaction with authority figures such as supervisor and/or managers. The examiner noted that GAF scores of 51 had been assigned and that the Veteran had not been able to return to work in any substantially gainful occupation to date. The examiner opined that the Veteran was considered to be entitled to a 100 percent rating for TDIU as of January 2009. The record also includes a September 2012 statement from his girlfriend. She indicated that it was difficult to maintain a relationship with the Veteran due to his mood swings, nightmares and nonchalant attitude with others and herself. She reported having to sleep in the guest room due to the Veteran's nightmares. She stated that she became fearful because he became so angry and then acted like nothing had happened. She concluded that the Veteran had a lot of mental issues that was affecting his social and personal life. Another opinion from the Veteran's therapist dated in October 2012 indicated that the Veteran displayed significant symptoms of PTSD as well as depression, including re-experiencing, recurrent images and thoughts, nightmares five to seven nights per week, flashbacks at least weekly, and psychological distress and physiological reactivity to trauma reminders. The Veteran also reported avoidance symptoms, trouble recalling parts of trauma, diminished interest in pleasurable activities, feeling detached from others and a restricted range of affect. He endorsed hyperarousal symptoms, interval insomnia, irritability, poor concentrating and excessive vigilance. His depression symptoms included depressed mood, loss of interest and pleasure, fatigue and difficulty concentrating. Despite compliance with therapy and medication, the Veteran continued to experience prolonged psychological sequelae. His most severe symptoms were depressed mood, chronic sleep impairment, anxiety, nightmares and emotional detachment. His PTSD symptoms continue to impede his ability to function both socially and occupationally. Therapy will continue on a weekly basis to assist in controlling these chronic and severe symptoms. Another opinion from the Veteran's VA psychiatrist dated that same month was also submitted. The examiner noted that the Veteran endorsed depressed mood, impaired sleep with recurrent traumatic nightmares, social isolation, hypervigilance and unprovoked irritability resulting in poor and ineffective interactions with others. The examiner concluded that the Veteran was compliant with his mental health treatment. At the Board hearing, the Veteran reported experience isolation, sleep impairment and nightmares. He indicated that he could not work due to his PTSD symptoms. He also reported trouble getting along with family members. On remand, the Veteran was afforded a VA examination in February 2016. After examining the Veteran and reviewing the record, the examiner found that the Veteran did not meet the criteria for a mental disorder diagnosis. The Veteran reported that he had one living brother who had early stages of dementia. The Veteran took his brother to doctors' appointments and they were the main support for each other. He was currently dating someone for a year and half and they got along fine. He had recently started speaking to his oldest daughter again after a big blowout over the grandkids. His granddaughter and grandson came down separately and spent time with him this past summer (both are adults now). He had only spoken to his youngest daughter once in the past couple of years. She had reported that the car he had given her was repossessed, her husband was an alcoholic and she lost a good job. He was able to take care of his activities of daily living and his niece came over and helped with house cleaning. The Veteran fished, watched television and watched and listened to baseball, but allergies kept him from going places. He had pulled back on voter registration volunteerism. He had some friends from the Vet Center that he communicated with most of the time. He also sometimes communicated with veterans that were stationed on the same ship with him. The Veteran reported nightmares and avoidance of going places, although the examiner noted that his records and treatment notes indicated that he was fairly active and social. He also reported anxiety attacks as an afterthought after several prompts by the examiner. On mental status examination, the Veteran was oriented to person, place, time, and situation. He was dressed and groomed appropriately. His thought processes were logical, organized, and goal-directed; there was no evidence that psychotic thought processes or behaviors interfered with his ability to relate to this examiner. His speech was thought congruent and normal in rate, tone, and volume. His mood was euthymic (normal) and pleasant; his affect was mood congruent mostly, however, at times it appeared that the Veteran was really trying to convince this examiner of how significantly he was impaired, particularly as noted below in the brief cognitive assessment given and in his testing results, which are discussed in the remarks section. He denied suicidal ideation, intent, or plan. In a brief cognitive assessment, the Veteran exhibited variable and unexplainable attention, concentration, hearing, confusion, and loss of crystallized knowledge issues that were not evident in any other portion of the examination. When this examiner asked him to immediately repeat a sequence of three words in the exact order as recited to him, he named all the words but switched the positions of the second and third words in the sequence. When prompted again, he took very long pauses between reciting the words back to this examiner, but gave the correct order. He stated that he had a hard time remembering things and he got a little confused sometimes. He took long pauses between letters when spelling the word "world" forward and when asked to spell it backward he exclaimed with an expletive, which was perceived as an attempt to underscore his reported issues by this examiner. He then repeated the letter "d" several times with long pauses in between before incorrectly spelling it backward by placing the "l" right before the "w." The Veteran went through a similar exercise of long pauses when asked to count backward by serial 3s from 20. He reported ignorance to how the government utilizes our tax dollars. When asked how an orange and a banana are alike he said, "That's a tricky question there, Doc. Most oranges, don't they put dye in 'em and bananas are yellow." This examiner then asked the Veteran what food group they belong to and he said, "I don't know that one." He followed those responses by accurately identifying how an airplane and a bird are alike/similar. The Veteran's approach to this portion of the examination and his responses indicate a clear lack of cooperation and effort with a gross attempt to exaggerate deficits in attention, concentration, crystallized knowledge, and memory. The Veteran was administered the Minnesota Multiphasic Personality Inventory, 2nd Edition, Restructured Form (MMPI-2-RF) for further assessment and diagnostic clarification. The Veteran's responses yielded the profile invalid due to gross exaggeration of symptoms not normally observed or reported within the genuine clinical population or psychopathological population as well as gross exaggeration of memory complaints. The memory complaints (RBS) scale is particularly sensitive to exaggeration of symptoms in forensic and disability examination settings. Additionally, he exaggerated somatic complaints not normally observed or reported within the genuine clinical population. The Veteran's suicidality scale score was very high despite the Veteran only endorsing past, passive thoughts of suicide and emphatically denying ever having any suicidal intent in the current examination. Due to the gross exaggeration of symptoms and resulting invalidity of his profile, the remainder of the clinical and content scales cannot be accurately interpreted as they reflect inflated scores commensurate with the overall invalid profile exaggeration. The examiner found that despite the Veteran having documented diagnoses of PTSD and depression in his treatment records, according to the Veteran's self-reported symptoms in the current examination, his overall psychosocial functioning reported in this examination and evident in his treatment records, he does not meet full DSM-5 diagnostic criteria for PTSD. Treatment providers generally do not have access to the full-range of records that are accessible in compensation examinations. Additionally, the available VA treatment records primarily record updates regarding the Veteran's nightmare frequency/intensity and interactions with his family without detailing his functioning related to other PTSD criteria. Likewise, the letter of support submitted by the Veteran from his Vet Center provider is based upon the Veteran's self-reported symptoms. These records are not based upon objective symptom measurement. Further, his gross exaggeration of cognitive impairments in the behavioral observations/mental status portion of this examination and his testing results recorded above clearly demonstrate the unreliability of his reported symptoms and frankly, make it impossible to attest to the validity of the presence of any mental health disorder or address any functional impairments related to the Veteran's ability to work. The examiner noted that the Veteran was retired and received retirement from Marta, SSA, and his VA compensation. In applying the rating criteria to the evidence of record, and resolving the benefit of the doubt in favor of the Veteran, the Board finds that the Veteran's PTSD more nearly approximates the criteria for a 50 percent evaluation from August 12, 2010. From this date, the Veteran exhibited symptoms that were more consistent with those characteristic of the criteria for a 50 percent rating, such as impairment of memory and disturbances of motivation and mood. Further, he reportedly showed difficulty in establishing and maintaining effective work and social relationships. In this regard, the August 2010 examiner found that the Veteran experienced mood disturbances and had difficulty establishing and maintaining relationships, which are criteria for a 50 percent rating. Follow up private and VA assessments continue to find that the Veteran had difficulty maintaining effective relationships. In sum, the Veteran's disability picture more nearly approximates the criteria for a 50 percent rating from August 12, 2010. However, the Board finds that the preponderance of the evidence is against a finding of occupational and social impairment with reduced reliability and productivity to warrant a 50 percent rating or higher prior to August 12, 2010. Although, arguably, the Veteran had disturbances of mood and motivation, which is a symptom under the 50 percent criteria, he did not exhibit symptoms such as flattened affect, circumstantial, circumlocutory, or stereotyped speech; more than once a week panic attacks; difficulty in understanding complex commands; impairment of short and long-term memory; impaired judgment; or impaired abstract thinking. Importantly, the April 2017 and March 2010 VA examiners during this period have also clearly determined that the Veteran exhibited occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally the person is functioning satisfactorily with routine behavior self-care and norm al conversation, which are the overall criteria for a 30 percent rating. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. Moreover, the Veteran was alert and oriented and cleanly dressed, with no loosening of associations, delusional thinking or loss of reality testing. The Board recognizes that the Court in Mauerhan v. Principi, 16 Vet. App. 436 (2002), stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. However, the Court further indicated that without those examples, differentiating a 30 percent evaluation from a 50 percent evaluation would be extremely ambiguous. Id at 442. In light of the Mauerhan case, the Board observes that the Veteran had been in a long term relationship with a common law spouse until her death in 2006 exhibiting his ability to maintain long term social relationships. The March 2010 VA examiner also observed that he was gainfully employed until his retirement. The Veteran was able to perform his activities of daily living during this period. In other words, the overall PTSD symptomatology during this period did not cause occupational and social impairment with reduced reliability and productivity. Therefore, the Board must conclude that the Veteran's impairment during this time period warranted a 30 percent rating for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The demonstrated PTSD symptomatology did not more nearly approximate the criteria for a higher rating. The Board recognizes that the Veteran's GAF scores ranged between 50 to 55 assigned during this period are indicative of moderate or serious symptoms that contemplate certain symptoms listed under the criteria for higher ratings. Nevertheless, the Board notes that a GAF score reflects merely an examiner's opinion of functioning levels and in essence represents an examiner's characterization of the level of disability that by regulation is not, alone, determinative of the appropriate disability rating. See Richard v. Brown, 9 Vet. App. 266, 267 (1996). It is noted that a disability rating depends on evaluation of all the evidence, and an examiner's classification of the level of a psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage disability rating to be assigned. 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (1995). In the instant case, despite the GAF scores assigned the demonstrated symptomatology does not persuasively show that the regulatory criteria for a 50 percent rating have been met. Moreover, the Board concludes that the preponderance of the evidence is against a finding of occupational and social impairment with deficiencies in most areas so to warrant the next higher rating of 70 percent at any time from August 12, 2010. In view of the aforementioned evidence, the Board finds that the Veteran's PTSD is primarily characterized by the following signs or symptoms: sleep impairment, nightmares, irritability, and depressed mood. Essentially, the Board finds that the Veteran's symptoms are similar to many of those contemplated by the currently assigned 50 percent rating. In particular, the General Rating Formula lists, inter alia, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, disturbances of mood and motivation, and impaired judgment, among the types of symptoms associated with a 50 percent rating. 38 C.F.R. § 4.130. These are not unlike those the Board finds to be associated with this Veteran's PTSD. Id. Further, given the frequency, nature, and duration of those symptoms, as reflected in the medical evidence, the Board finds that they result in no more than occupational and social impairment with reduced reliability and productivity. They do not more closely approximate the types of symptoms contemplated by a 70 percent rating, and therefore, a 70 percent rating is not warranted. See Vazquez-Claudio, 713 F.3d at 114 (holding that a Veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). The Board recognizes that the August 2010, November 2010, and October 2012 opinions from the Veteran's Vet Center treating therapist and VA psychiatrist describes the Veteran's PTSD symptoms as chronic and severe and the November 2010 psychiatrist indicated that the Veteran had an inability to maintain effective relationships. The July 2012 Vocational Assessment also indicated that the Veteran was unable to engage in substantial gainful employment since 2009. Nevertheless, the August 2010 opinion found that the Veteran had difficulty establishing and maintaining social relationships, which is one of the criteria for a 50 percent rating. Moreover, the symptoms described in these evaluations are primarily those contemplated in the current 50 percent rating. In this regard, the examiners primarily reported that the Veteran's symptoms are sleep impairment, irritability, poor concentration, hypervigilance, depressed mood and lack of activities, all of which are contemplated in the 50 percent criteria. Significantly, the evidence shows that the Veteran has been able to perform his activities of daily living, maintain friendships with other veterans and engage in social activities. The Board also finds it significant that the most recent VA examiner found that these records were not accurate reflections of the Veteran's functional impairment as they were based on the Veteran's self-reported symptoms and no objective testing. The examiner continued that due to the Veteran's gross exaggeration of cognitive impairments in the behavioral observations/mental status portion of that examination and his testing results recorded clearly demonstrate the unreliability of his reported symptoms and make it impossible to attest to the validity of the presence of any mental health disorder or address any functional impairment. The Board notes that although the 70 percent rating criteria contemplate deficiencies in "most areas," including work, school, family relations, judgment, thinking, or mood, such deficiencies must be "due to" the symptoms listed for that rating level, "or others or others of similar severity, frequency, and duration." Vazquez-Claudio, supra. That is, simply because this Veteran has depressed mood, and because the 70 percent level contemplates a deficiency these symptoms among other areas, does not mean his PTSD rises to the 70 percent level. Indeed, the 50 percent criteria contemplate some form of mood impairment. Furthermore, at no point during the course of the appeal has the Veteran exhibited symptoms such as near continuous panic, obsessional rituals or neglect of personal hygiene, impaired impulse control or suicidal/homicidal ideation. Also, his anxiety or depression did not affect his ability to function independently, and the Veteran's speech was never illogical, obscure or irrelevant. Rather, his speech was normal rate, rhythm and amount. He was consistently alert and oriented to place and person. There was no impairment of thought processes or communication. Again, the most recent examiner found that the Veteran's reports of memory impairment were grossly exaggerated. Importantly, as noted above, he has been able to perform his activities of daily living. The Board recognizes that the Veteran's GAF score listed in the VA clinical records has been 50, which is indicative of more serious symptoms. Nevertheless, again, a GAF score reflects merely an examiner's opinion of functioning levels and in essence represents an examiner's characterization of the level of disability that by regulation is not, alone, determinative of the appropriate disability rating. See Richard v. Brown, 9 Vet. App. 266, 267 (1996). It is noted that a disability rating depends on evaluation of all the evidence, and an examiner's classification of the level of a psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage disability rating to be assigned. 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (1995). Nevertheless, despite these GAF scores, in the Board's view, as discussed above, the demonstrated symptomatology does not persuasively show that the regulatory criteria for a 70 percent rating have been met given the Veteran's actual symptomatology. In sum, because the lower GAF scores are not consistent with the objective findings, the scores are not probative as to the Veteran's actual disability picture. Moreover, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met. In this regard, the evidence does not show that the Veteran has total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In sum, the Veteran's symptoms do not more nearly approximate the criteria for a 70 or 100 percent disability rating. The criteria for a 50 percent rating appear to more accurately describe the Veteran's level of social and occupational impairment, including disturbances in motivation and mood and difficulty in establishing social relationships. The Board finds that his PTSD impairment from August 12, 2010 is adequately contemplated by the 50 percent rating. In determining that the criteria for a rating in excess of 50 percent for the Veteran's service-connected PTSD are not met, the Board has considered the applicable rating criteria not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for the psychiatric disability in question. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board has carefully reviewed and considered the Veteran's and his girlfriend's statements regarding the severity of his PTSD. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Moreover, the Board has contemplated the Veteran's and his girlfriend's statements concerning the severity of his symptoms when assigning the current 50 percent disability rating August 12, 2010. The Board has considered whether further staged ratings are appropriate for the Veteran's service-connected PTSD. See Fenderson, supra. However, the Board find that his symptomatology has been stable both before and after August 12, 2010; therefore, assigning further staged ratings for such disability is not warranted. In conclusion, an initial 50 percent rating, but no higher, is warranted for the Veteran's service-connected PTSD, effective August 12, 2010. The Board, however, finds that the preponderance of the evidence is against the Veteran's claim for an initial rating in excess of 30 percent prior to August 12, 2010, and in excess of 50 percent thereafter. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. III. TDIU The Veteran is seeking entitlement to TDIU. He has asserted that he is unable to work to his service-connected PTSD. In order to establish service connection for a total rating based upon individual unemployability due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. VA regulations establish objective and subjective standards for an award of total rating based on unemployability. When the Veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned when there is only one such disability, such is ratable at 60 percent or more and, if are two or more disabilities, at least one disability is ratable at 40 percent or more, and any additional disabilities result in a combined rating of 70 percent or more, and the disabled person is unable to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(a). A total disability rating may also be assigned on an extra-schedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). The Veteran is service connected for PTSD, evaluated as 30 percent disabling prior to August 12, 2010, and 50 percent disabling thereafter, and allergic rhinitis, evaluated as noncompensable. As such, the Veteran's combined rating is 50 percent and, thus, he does not meet the scheduler criteria for a TDIU. However, it is VA policy that all Veterans who are unable to work due to a service connected disability will be awarded TDIU. 38 C.F.R. § 4.16(b). Where a Veteran does not meet the percentage requirements, but there is evidence of unemployability, the claim for TDIU will be referred to the Director of VA's Compensation and Pension Service. 38 C.F.R. § 4.16(b). If the Veteran does not meet the percentage requirements, the Board cannot grant TDIU in the first instance, but must first insure that the TDIU claim is referred to the Director of Compensation and Pension (C&P) for adjudication. Bowling v. Principi, 15 Vet. App. 1 (2001). Therefore, the Board must determine whether there is evidence of unemployability to warrant referral to the Director of C&P. Factors such as employment history, as well as educational and vocational attainments, are for consideration. The Board emphasizes that a total rating based on individual unemployability is limited to consideration of service-connected disabilities. The Board notes that the ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator. 38 C.F.R. § 4.16(a); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). However, medical examiners are responsible for providing a full description of the effects of disability upon the person's ordinary activity. 38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). Based on the evidence of record, the Board finds that the Veteran is not unemployable due to his service-connected disabilities. As such, referral to the Director of C&P for extraschedular consideration is not warranted. Initially, the Board observes that the evidence does not show and the Veteran has not asserted that his service-connected allergic rhinitis impacts his ability to work. He has primarily asserted that he is unable to work due to his PTSD. However, in this regard, while the medical evidence observed some limitations that impacted the Veteran's ability to work, the probative evidence of record does not support the finding that the Veteran's PTSD precludes his ability to work. Rather the evidence shows that the Veteran retired in 2004 after working as a bus driver for 30 years. Although the July 2012 Vocational Assessment opined that the Veteran was unemployable, again, the symptoms described by the examiner do not document such functional impairment. The Board also finds it significant that the Vocational expert indicated that in his previous job as a bus driver, the Veteran was able to work on a socially isolated basis. However, the record previously documented that the Veteran had good relationships with his supervisor and co-workers and was in constant contact with the public. Thus, it appears that the examiner relied on an inaccurate description of the Veteran's prior job. Significantly, the most recent VA examiner clearly found that based on objective testing, the Veteran's symptoms were previously grossly exaggerated making it impossible to attest to the validity of the presence of any mental health disorder or address any functional impairments related to the Veteran's ability to work. As such, given that the July 2012 assessment relied on the Veteran's self-reported symptoms and no objective testing, it does not appear that it is an accurate assessment of the Veteran's occupational impairment. In light of the above, the Board must find that this assessment has minimal probative value and is outweighed by the remaining evidence of record. Importantly, the evidence shows that the Veteran has been able to perform his activities of daily living. He also volunteered for many years. The Board also finds it significant that the Veteran himself reported in 2005 that he while working as a bus driver, he was able to manage his PTSD symptoms, but since retirement in February 2004, he did not have enough structure to occupy his time. At the subsequent VA examinations, it was documented that he was able to work for 30 years coming into close contact with the public as a bus driver with no problems. Furthermore, to the extent that the Veteran and/or his representative have attempted to establish the Veteran's entitlement to a TDIU on the basis of lay assertions alone, the Board emphasizes that neither the Veteran nor his representative is shown to possess expertise in medical or vocational matters. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Rather, while they are competent to describe the Veteran's difficulty hearing at various times, to include while at work, they are not competent to offer an opinion regarding the functional impact such has on his ability to maintain gainful employment in a variety of fields. Hence, the lay assertions in this regard have no probative value and are outweighed by the more probative medical opinions. In this regard, the competent medical evidence offering detailed specific specialized determinations on the Veteran's functional impairment are the most probative evidence; the medical evidence also largely contemplates the Veteran's assertions concerning his employment and descriptions of symptoms. For the foregoing reasons, the Board finds that the Veteran's service-connected disabilities do not preclude substantially gainful employment. In conclusion, the preponderance of the evidence is against entitlement to a TDIU due to service-connected disabilities. It follows that there is not such a balance of the positive evidence with the negative evidence to otherwise permit a favorable determination on this issue. 38 U.S.C.A. § 5107(b). ORDER Prior to August 12, 2010, an initial rating in excess of 30 percent for PTSD is denied. From August 12, 2010, a 50 percent rating, but no higher, for PTSD is granted, subject to the laws and regulations governing payment of monetary benefits. A TDIU is denied. ____________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs