Citation Nr: 1805906 Decision Date: 01/30/18 Archive Date: 02/07/18 DOCKET NO. 10-26 311 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities. 2. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 3. Entitlement to a total evaluation based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION The Veteran represented by: Robert V. Chisholm, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD I. M. Hitchcock, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1967 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2009 and September 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In March 2012, the Veteran testified at a videoconference hearing before the undersigned Veteran's Law Judge (VLJ). A transcript of this hearing has been associated with the claims file. In May 2014, The Board remanded the above claims for additional development. The Board again remanded the claims for service connection for peripheral neuropathy and entitlement to TDIU in September 2016. The Board once again remanded those claims in July 2017. All development for the remands has been completed. In September 2016, the Board issued a decision finding that the Veteran was entitled to an initial rating of 50 percent for PTSD. The Veteran appealed this finding to the Court of Appeals for Veterans Claims (Court). In June 2017, a Joint Motion for Partial Remand (JMPR) returned the decision to the Board to address deficiencies in the September 2016 decision. FINDINGS OF FACT 1. The Veteran's peripheral neuropathy of the bilateral upper and lower extremities was not caused or etiologically related to his military service. 2. Throughout the course of the appeal, from March 5, 2008 until October 31, 2016, the Veteran's PTSD has been manifested by no more than occupational and social impairment with reduced reliability and productivity due to symptoms of sleep impairment, nightmares, intrusive memories, irritability, anxiety, depression, hypervigilance, exaggerated startle response, flattened affect, and difficulty in establishing and maintaining effective work and social relationships. The evidence of record also shows that the Veteran was alert and fully oriented, with good hygiene, normal speech, clear and logical thought processes. 3. As of November 1, 2016, the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability; and the inability to establish and maintain effective relationships, but has not prevented a total impairment in occupational and social functioning. 4. Throughout the course of the appeal, the Veteran's service-connected disabilities have prevented him from obtaining and maintaining substantially gainful employment consistent with his educational and vocational experience. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy of the bilateral upper and lower extremities have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303 (2017). 2. The criteria for an initial evaluation of 50 percent, but no more, for PTSD have been met for the period until October 31, 2016. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 3. As of November 1, 2016, the criteria for an evaluation of 70 percent, but no more, for PTSD have been met. Id. 4. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.10, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Under 38 U.S.C. §§ 1116(a)(2) and 38 C.F.R. § 3.309(e), Veterans who served in Vietnam during a certain time period, and who have certain diseases, may be presumed to have those diseases as a result from exposure to herbicide agents, such as Agent Orange. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that his peripheral neuropathy is a result of exposure to chemical agents, to include Agent Orange. Specifically, the Veteran asserts that he developed severe pancreatitis and his doctors have told him that the peripheral neuropathy, which is secondary to the pancreatitis, was a result of some sort of chemical exposure. The Veteran has a current diagnosis of peripheral neuropathy. Therefore, the first prong of service connection is met. Shedden, supra. According to the Veteran's service treatment records, he served in the Republic of Vietnam during the Vietnam Era; therefore, his exposure to toxic herbicides is presumed. Therefore, the second criteria for service connection, whether there was an in-service event, has been satisfied. Id. As to third element, whether there exists a nexus between the current disability and the in-service event, the Board first notes that peripheral neuropathy is not a listed disability in 38 C.F.R. 3.309(e). As a consequence, service connection on a presumptive basis is not warranted. Therefore, in order to be service-connected for peripheral neuropathy, the Veteran must prove that his disease is connected with his service. The medical record, hearing testimony, and other statements have been reviewed in considering the Veteran's claim. The Board notes that the Veteran's service treatment records (STRs) are silent as to any complaints or diagnosis related to peripheral neuropathy of the Veteran's upper and lower extremities. The Veteran developed pancreatitis in late 2006 and was admitted to the hospital for an extended stay into 2007. In June 2008, the Veteran met with a doctor to discuss his post-hospital stay related to pancreatitis. The doctor noted that the Veteran did not drink alcohol and was on an unspecified antibiotic prior to his abrupt illness. The doctor found that his pancreatitis is most likely related to biliary tract gallstone disease and possibly from hyperlidemia. Neither of these conditions are service-connected diseases. The Veteran applied for disability with the Social Security Administration. Statements made in connection with that application indicate that the Veteran blamed his pain and cramping on his pancreatitis and not to anything overtly related to service. In a May 2011 treatment record, the Veteran was noted to be a vague historian. The Veteran contended that while he had right leg pain since 1969, he has had cramping and tingling of his hands and legs in the prior two years. The Veteran attended a consultation for his peripheral neuropathy with Dr. T in December 2013. Dr. T. noted the Veteran's Agent Orange exposure, "which could be a reason" that the Veteran has peripheral neuropathy. While this doctor gives an opinion linking the Veteran's current diagnosis with an in-service event, the opinion is speculative because the doctor notes it only "could be a reason" that the Agent Orange caused peripheral neuropathy. See Obert v. Brown, 5 Vet. App. 30, 33 (1995); Tirpak v. Derwinski, 2 Vet. App. 509, 611 (1992). Therefore, this opinion is given little probative weight. In conjunction with his claim, the Veteran has been afforded several VA examinations. An examination was conducted in September 2014. After a thorough review of the record and following a complete examination of the Veteran, the examiner diagnosed idiopathic polyneuropathy of the upper and lower extremities. It was opined that it was less likely than not that the diagnosed polyneuropathy was caused by service or was otherwise related to or aggravated by service. The service treatment records had reflected complaints of cramping; however, no diagnosis was ever made. There were no complaints of, treatment for, or diagnosis of polyneuropathy in service. There was no documentation of this condition in years immediately following service that would demonstrate chronicity since his release from service. The examiner also found no causal connection between his service-connected varicose veins and his peripheral (which affected all his extremities, not just the right leg). An October 2016 VA examiner opined that it is less likely than not that the peripheral neuropathy is secondary to, or aggravated by, his service connected PTSD, post-phlebetic syndrome, and tinnitus, because all of those disease have different etiologies, symptoms, anatomical origins, and there is no cause and effect relationship between those diseases and peripheral neuropathy. It was also noted that there was no evidence of peripheral neuropathy in the service treatment records, nor was such a condition noted within one year of the Veteran's last exposure to herbicides. Therefore, the examiner concluded that direct and presumptive service connection were not supported by the evidence of record. The Veteran had a VA examination in January 2017. The VA examiner gave the opinion that it is less likely than not that the peripheral neuropathy was incurred in or caused by service. In support of the finding, the examiner noted that there was no note of neuropathy in service and the diagnosis first arose in 2013. Further, the examiner gave the opinion that it is less likely than not that the peripheral neuropathy is secondary to, or aggravated by, his service connected varicose veins in his right leg. In support of this opinion, the examiner pointed out that the Veteran's complaints are not limited to the right lower extremity alone. In addition, the medical literature supports that a non-focal distribution of neuropathy cannot occur by a right lower extremity condition. Moreover, the examination had found no clinical findings of varicose veins/edema in the right leg that would cause any neuropathy condition. In the most recent examination, in August 2017, once again the Veteran's file was reviewed. The VA examiner first found that peripheral neuropathy due to chemical exposure is an acute condition which happens within 1 year of exposure and there is no documentation in the Veteran's service treatment records to that fact. The examiner went on to state that the etiology of his peripheral neuropathy of all extremities is not clear. However, considering the Veteran's lower extremities and given the evidence of record, the Veteran's neurologist suspected radiculopathy, and the Veteran had lumbar disc problems since 2011. Further, when considering the Veteran's upper extremities, imaging studies indicated carpal tunnel syndrome and elbow nerve entrapment. The examiner stated the following: "It is not possible to explain every symptom and every test, [as] neurological issues are complex and even the neurology specialist could not pinpoint the etiology." However, given the record, the examiner gave the opinion that it is less likely than not that peripheral neuropathy was caused by or aggravated in the service or by his current service-connected conditions. The findings of this examiner are similar to the September 2014 VA examination. Upon consideration of the above evidence, the Board finds that the preponderance of the evidence is against the claim for service connection for peripheral neuropathy. The Board notes that the Veteran's STRs are silent as to any treatment, diagnosis, or complaints of problems related to peripheral neuropathy while in service. Relevant post-service treatment records reflect that the Veteran's was first diagnosed with peripheral neuropathy well after his discharge from service. The Board accords great probative weight to the collective VA examiners' opinions that the Veteran's peripheral neuropathy was not incurred in or a result of the Veteran's service, nor secondary to any of his service-connected conditions, as the opinions are predicated on a detailed review of the records, including his STRs and VA examinations. The VA examiners' opinions sufficiently address the potential link between the present peripheral neuropathy and service and contain clear conclusions with supporting data, as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Based on the foregoing, the Board finds that service connection is not warranted for peripheral neuropathy. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. Given that no ultimate, material issues are in equipoise, that doctrine is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. II. Increased Rating A. Initial rating from March 5, 2008 until October 31, 2016 The Veteran challenges the initial 50 percent disability rating assigned for his service-connected PTSD. He filed a claim of entitlement to service connection for PTSD in March 2008. The Board will consider whether a higher rating is warranted for any portion of the appeal period. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2017). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where an appeal is based on an initial rating for a disability, as in the instant case, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). As explained in more detail below, the Board finds that the Veteran's disability increased starting November 1, 2016. PTSD is rated under Diagnostic Code (DC), 9411 which falls under the Schedule of ratings for Mental Disorders in 38 C.F.R. § 4.130. Pursuant to DC 9411, a 50 percent rating is warranted when there is evidence demonstrating 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, such as 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. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is warranted when there is evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A rating of 100 percent is warranted when the evidence shows 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, to include maintenance of minimal personal hygiene; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Id. The "such symptoms as" language of the DCs for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. While each of the examples need not be proven in any one case, the particular symptoms must be analyzed in light of the given examples. Put another way, the severity represented by those examples may not be ignored. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated 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." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders so as to replace outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). VA directed that the changes be applied only to applications for benefits received by VA or pending before the agency of original jurisdiction (AOJ) on or after August 4, 2014, but not to claims certified to, or pending before, the Board, the CAVC, or the United States Court of Appeals for the Federal Circuit. Id. As the Veteran's claim was certified to the Board in July 2010 (prior to August 4, 2014), this regulatory amendment does not apply in this matter. It is worth noting, however, that this regulatory amendment does not affect evaluations assigned to mental disorders because the update did not change the disability evaluation criteria in 38 C.F.R. § 4.130, the Schedule for Ratings for Mental Disorders. Id. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DSM-IV; Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a score of 41-50 illustrates "[s]erious 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)." See 38 C.F.R. §§ 4.125, 4.130. A GAF score between 51 and 60 reflects moderate symptoms, such as flat affect and circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational, or school functioning. Id. While a GAF score can be 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, the GAF scores assigned in a case are not dispositive of whether a higher evaluation is warranted; rather, they must be considered in light of the actual symptoms of the Veteran's disorder. See 38 C.F.R. § 4.126(a). While the Board has considered the degree of functioning as evidenced by this reported range of GAF scores, it is but one factor for consideration in assigning a rating in this case. See Brambly v. Principi, 17 Vet. App. 20, 26 (2003). Throughout the course of the appeal, the Veteran's PTSD has been assigned GAF scores ranging from 50 to 70. Specifically, an initial February 2008 VA psychiatric report shows a GAF score of 55. Thereafter, the Veteran received GAF scores of 55 in February 2008, 60 in August 2008, 60 in October 2008, 58 in December 2008, 58 in January 2009, 65 in May 2009, 70 in October 2010, 50 in April 2011, 50 in July 2011, 55 in October 2011, 55 in January 2012, 55 in April 2012, 55 in July 2012, 55 in October 2012, 55 in March 2013, 55 in June 2013, and 55 in September 2013. While the Board has considered the degree of functioning as evidenced by this reported range of GAF scores, it is but one factor for consideration in assigning a rating in this case. See Brambly v. Principi, 17 Vet. App. 20, 26 (2003). The Veteran initially sought treatment for PTSD symptoms at VA in February 2008. He reported nightmares of Vietnam as well as having on and off daytime thoughts of Vietnam. On mental status examination, the Veteran was alert and attentive, with appropriate grooming. Speech was at a normal rate and rhythm, and the Veteran's language was intact. Affect was congruent with mood, labile with wide range. There were no perceptual disturbances reported, and the Veteran had normal, coherent, and circumstantial thought process and association. At that time, the attending physician found suicidal ideation. However, it was passive without a plan. Insight was good, judgement was good, memory was intact, and the Veteran had an average fund of knowledge. VA first afforded the Veteran an examination for PTSD in January 2009. The examiner noted that the Veteran had been married for 42 years and had two grown children. The Veteran indicated his wife had complained that he was "mean to her at times", and he reported having nightmares. The Veteran reportedly had no real close friends, and he had little interest in social activities. On examination, the Veteran was casually dressed. The examiner noted hand wringing, repetitive acts, restlessness, and tenseness. The Veteran's speech was unremarkable. His attitude was cooperative but guarded. Affect was appropriate. Mood was anxious and dysphoric. Attention was intact. He had good concentration. The Veteran was oriented to person, time, and place. Regarding thought process, the examiner noted the Veteran had an overabundance of ideas as well as circumstantiality. There was suicidal ideation present. The Veteran further reported having sleep impairment. It would begin with delayed sleep onset. Thereafter, the Veteran would toss and turn and "dream of Vietnam all the time." The Veteran recalled having nightmares every night, and he would wake up feeling "groggy." The examiner noted that the Veteran had inappropriate behavior in that his constant circumstantiality would interfere with ordinary conversation. However, the Veteran interpreted proverbs appropriately; he did not have obsessive or ritualistic behavior, panic attacks, or homicidal thoughts. Again, the examiner affirmed the Veteran had suicidal ideations. However, the Veteran had no plans regarding suicide. Regarding present symptoms, the examiner listed persistent re-experiencing of the traumatic event by recurrent and intrusive distressing recollections of the event, including images, thoughts, perceptions, and nightmares. The Veteran also showed avoidance symptoms, manifested by efforts to avoid thoughts, feelings, or conversations associated with the trauma he sustained while in Vietnam. He showed efforts to avoid activities, places, or people that aroused recollections of the trauma. He had a feeling of detachment or estrangement from others. The Veteran had persistent symptoms of increased arousal, manifested by difficulty falling or staying asleep, irritability or outburst of anger, and hypervigilance. The examiner commented that the Veteran's PTSD symptoms became severe after his December 2007 hospitalization for pancreatitis. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 58. He concluded that the Veteran's PTSD resulted in moderate difficulty in social and occupational functioning. Subsequent VA treatment records document numerous instances of psychiatric treatment over the course of the appeal, from which the Board has extracted the assigned GAF values as listed earlier. From January 2009, VA treatment records have documented psychiatric symptoms attributable to PTSD such as adequate hygiene and dress, normal psychomotor function, irritable mood, congruent effect, normal speech, normal thought process, normal thought content, no delusions, suicidal, or homicidal ideation, and fair insight and judgment. In the March 2012 hearing, the Veteran described reliving his experiences in Vietnam. Specifically, he described having nightmares about Vietnam. He also described isolative tendencies and difficulties with memory. The Veteran testified that he would experience feelings of nervousness, sleep disturbances, and times where he is uncomfortable. The Veteran had a subsequent VA psychiatric examination in September 2014. At that time, the examiner confirmed the Veteran had PTSD and denied that there were any other psychiatric diagnoses. During the clinical interview, the Veteran reported still being married to his wife of 47 years. He reported having two grown children with five grandchildren. The Veteran reported seeing his grandchildren and "doing as much as [he] can" with them. The Veteran reported volunteering as a chaplain for the Lee County Sheriff's Department, sometimes four to five times per month. He would provide counseling, and he also performed weddings for servicemen. After an evaluation, the examiner found that the Veteran's PTSD manifested as depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a work-like setting. The examiner concluded that 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, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran was mildly dysphoric and irritable; however, no anxiety, hypervigilance, or hyper-startle reaction were noted on examination. Regarding functional impact, the examiner noted that the Veteran's PTSD in itself does not preclude him from obtaining and maintaining gainful employment. Supporting this conclusion, the examiner noted that the Veteran continued to provide services as a chaplain to the Lee County Sheriff's department and continued to perform weddings. After a thorough review of the record, the Board concludes that an initial 50 percent evaluation is warranted for the Veteran's service-connected PTSD from March 5, 2008 through October 31, 2016. 38 C.F.R. § 4.130, DC 9411. Since the initial grant of service connection, the Veteran's PTSD has been manifested by sleep impairment, nightmares, suspiciousness, disturbances of motivation and mood, irritability, anxiety, depression, hypervigilance, flattened affect, and difficulty in adapting to stressful circumstances, including work or a work-like setting. For the period of the appeal where GAF scores were assigned, the Board notes that the values were predominantly between 50 and 60. These values, as noted above, reflect moderate symptoms such as flat affect and circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational, or school functioning. These values support the assignment of a 50 percent evaluation. At no point since the initial grant of service connection until October 31, 2016, does the evidence of record reflect symptoms that resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood to warrant a 70 percent rating. The Veteran's PTSD has not been manifested by symptoms analogous in severity to 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. To the contrary, the evidence of record shows that the Veteran was alert and fully oriented, with good hygiene, normal speech, clear and logical thought processes, and no homicidal ideation. The Board notes that the Veteran did report suicidal ideation at times during 2008 and 2009, at the beginning of the appeal period. However, VA treatment notes document that the Veteran also denied suicidal ideation from 2010 until after October 31, 2016. The Board notes that typically, suicidal ideation as a symptom is more commonly associated with a 70 percent rating in the general rating formula for mental disorders. However, as noted above, the evidence does not show obsessional rituals that interfere with routine activities, illogical or obscure speech, near-continuous panic or depression, impaired impulse control, spatial disorientation, and an inability to establish and maintain effective relationships, symptoms also associated with a 70 percent rating. The absence of these symptoms is not outcome determinative. However, the Veteran also failed to show other symptoms of similar severity, frequency, and duration. The presence of suicidal ideation alone in this context, where the ideation was passive and intermittent, does not rise to the level of severity of the symptomatology required for a 70 percent rating, i.e. occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood. See Vasquez-Claudio v. Shinseki, 713 F.3d 112 (2013). Of note, in the June 2017 JMPR, it was asserted that Veteran had "impaired impulse control, such as unprovoked irritability with periods of violence." In support of this assertion, the Veteran points to a January 2009 VA examination where the examiner noted that "the Veteran would have problems getting along with coworkers/bosses because of irritability, also some absenteeism." Further, in a September 2014, VA examination, the Veteran "had irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects." The JMPR also notes that the Veteran had "difficulty adapting to stressful situations" noting the Veteran's suicidal ideation. The probative evidence of record establishes that the Veteran does not have "impaired impulse control" or "difficulty adapting to stressful situations" which would warrant a 70 percent rating prior to November 1, 2016. There is one instance of an episode of violence toward anyone, the Veteran's wife, but that was during a nightmare and early in the appellate period. Further, the Veteran continued to perform weddings and provide counseling services, belying a serious work or social deficiency. Regarding the Veteran's ability to adapt, the Board notes that the Veteran had suicidal ideations as discussed above. At the VA examination in September 2014, the examiner notes the diagnostic criteria for the Veteran's PTSD and current symptoms, but the examiner does not note the severity of these symptoms. However, the examiner does note the following in the behavioral observation section: "Veteran is a very nice 67 year old man who is pleasant and cooperative with the interview. Veteran is mildly dysphoric and irritable. No anxiety, hypervigilance, or hyperstartle reaction is noted on examination." The medical record does not reveal consistent findings that are contrary to this observation. The preponderance of the evidence of record does not show occupational and social impairment that meets the criteria for a rating in excess of 50 percent for the Veteran's service-connected PTSD at any point since the initial grant of service connection until October 31, 2016. Accordingly, the doctrine of reasonable doubt is not for application, and therefore, a rating in excess of 50 percent for the Veteran's service-connected PTSD is not warranted. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). B. After November 1, 2016 However, the Board finds that after November 1, 2016, the Veteran's symptoms have risen in severity such that a 70 percent evaluation is warranted. In a VA treatment record in November 2016, the Veteran reported that he felt he could no longer perform wedding ceremonies because he felt ashamed of his disabilities. He was noted to be intense, focused, questioning, and anxious, with intense affect. The Veteran reported suicidal ideation in the past 30 days. In the most recent VA medical records, the Veteran's mental status examination is similar in presentation with the Veteran being noticeably more anxious, irritable, and angry. Given this, the Board finds that as of November 1, 2016, a 70 percent evaluation is warranted because there is evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability; and the inability to establish and maintain effective relationships. Id. However, at no time is a 100 percent evaluation warranted because the evidence does not show total occupational and social impairment. The preponderance of the evidence of record does not show occupational and social impairment that meets the criteria for a rating in excess of 70 percent for the Veteran's service-connected PTSD since November 1, 2016. Accordingly, the doctrine of reasonable doubt is not for application, and therefore, a rating in excess of 70 percent for the Veteran's service-connected PTSD is not warranted. III. Total Disability on the Basis of Individual Unemployability (TDIU) The Veteran testified he has not worked since 2008, when he left a job at Comcast due to complications from pancreatitis. He claims he is entitled to TDIU, asserting his disabilities make him unemployable. Total (100 percent) disability ratings will be assigned "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). A total disability rating may be assigned under a DC where the DC associated with a disability prescribes a 100 percent disability rating. Additionally, regulations provide other methods by which TDIU may be awarded. TDIU may be assigned to a veteran who is "unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities" provided that he has received a disability rating of 60 percent or greater, or if he is service-connected for two or more disabilities, at least one of those disabilities has been assigned a disability rating greater than 40 percent, and the combined disability rating for all disorders is at least 70 percent. 38 C.F.R. § 4.16(a). For the entire period on appeal, the Veteran has at least one disability rated 40 percent or greater, and his combined disability ratings exceed 70 percent (see Veteran's disability ratings, supra). In consideration of the evidence of record, the Board finds that it does show that the Veteran's service-connected disabilities, in combination, preclude him from securing and following a substantially gainful occupation. "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Evidence mitigating in the Veteran's favor include his testimony before the Board that the pain from his right leg disability interferes with his ability to concentrate. Further, the pain medications he must take further reduces his ability to focus. In addition, the Veteran's PTSD affects his ability to interact with others. His sleep is affected due to nightmares, thus further impacting his ability to sustain concentration and keep up pace at work. There have been several VA examinations noting that the Veteran continued to perform wedding services and that he was terminated from his last job because of complications from pancreatitis. However, volunteer work and wedding services does not appear to be a substantially gainful occupation. The Veteran's earnings records show that he did not earn money from 2008 forward. In addition, the Veteran's PTSD increased in severity; thus, his work functioning would necessarily worsen with an increase in symptoms. Further, these VA opinions do not address how his symptomology would affect his ability to work. See VA exams in January 2009, May 2014, September 2014, October 2016, and January 2017. Therefore, the Board gives these opinions little probative weight. The Veteran submitted an October 2017 private vocational opinion from S.G. The opinion reviews the Veteran's employment history, education, and his symptoms throughout the record. S.G. is a certified rehabilitation counselor and has over 20 years of experience in vocational counseling. S.G. gave the opinion that it is at least as likely as not that the Veteran has been unable to secure and follow substantially gainful employment due solely to his service-connected PTSD and right leg venous insufficiency since 2007. The Board gives this opinion great probative weight because it considers the Veteran's longitudinal work history, his symptomology, and because it is from a licensed rehabilitation counselor. At most, the medical evidence of record establishes the Veteran would need to work in a very restricted work environment with no contact with the public or with co-workers, and while he might be able to engage in at least simple sedentary tasks, he is unable to maintain substantially gainful employment due to the limitations placed on his work environment by his service-connected psychiatric condition. After considering the evidence for and against the claim, the Board finds the evidence at least equipoise as to whether the Veteran's service-connected disabilities have rendered him unemployable. As such, a reasonable doubt arises as to his employability, which is resolved in favor of the Veteran. 38 U.S.C. § 107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). ORDER The criteria for service connection for peripheral neuropathy of the bilateral upper and lower extremities have not been met. The criteria for an initial evaluation of 50 percent, but no more, for PTSD have been met for the period from March 5, 2008 until October 31, 2016. As of November 1, 2016, an evaluation of 70 percent, but no more, for PTSD has been met. The criteria for TDIU have been met. ____________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs