Citation Nr: 18144185 Decision Date: 10/24/18 Archive Date: 10/23/18 DOCKET NO. 10-48 434 DATE: October 24, 2018 ORDER An initial evaluation of 70 percent, but not in excess thereof for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is granted, subject to the laws and regulations governing the payment of VA benefits. An effective date earlier than October 16, 1992, for an award of service connection for an acquired psychiatric disability, to include PTSD, is denied. A total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. For the period on appeal prior to November 7, 1996, the Veteran’s acquired psychiatric disability was productive of severe impairment of the ability to establish maintain effective or favorable relationships with symptoms of such severity and persistence that there was severe impairment in the ability to obtain or retain employment; thereafter, it was productive of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood. 2. Subsequent to a final May 1971 rating decision denying service connection for an acquired psychiatric disability, the Veteran did not file a claim to reopen until October 16, 1992. 3. The Veteran’s service-connected disabilities have not rendered him unemployable or unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 70 percent, but not in excess thereof, for an acquired psychiatric disability, to include PTSD, have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (1992, 2017). 2. The criteria for an effective date prior to October 16, 1992, for an award of service connection for an acquired psychiatric disability, to include PTSD, have not been met. 38 U.S.C.A §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.400 (2017). 3. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1968 to March 1970. This appeal is before the Board of Veterans’ Appeals (Board) from a July 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In September 2014, the Board remanded the Veteran’s appeal with instruction to determine when relevant service treatment records had been added to the claims file. His service treatment records were re-scanned into his electronic file, including date-stamps on the rear of the documents that indicating when they were initially received by VA. The Board is therefore satisfied that the instructions in its September 2014 remand have been satisfactorily complied with. See Stegall v. West, 11 Vet. App. 268 (1998) 1. Entitlement to an initial evaluation in excess of 50 percent for an acquired psychiatric disability, to include PTSD The Veteran seeks an increase to his rating for PTSD. Disability evaluations are determined by application of the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran’s ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. The criteria for this code were amended, effective November 7, 1996. See 61 Fed. Reg. 52,695-702 (Oct. 8, 1996) (codified at 38 C.F.R. §§ 4.125-130 (1999)). Where the law or regulation changes during the pendency of a case, the version most favorable to the veteran will generally be applied. See West v. Brown, 7 Vet. App. 70 (1994); Hayes v. Brown, 5 Vet. App. 60 (1993); Karnas v. Derwinski, 1 Vet. App. 308 (1991). The later criteria, however, even if more favorable, may be applied only from the effective date of the change forward, unless the regulatory change specifically permits retroactive application. 38 U.S.C. § 5110(g); VAOPGCPREC No. 7-2003 (Nov. 19, 2003); VAOPGCPREC No. 3-2000 (April 10, 2000); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under the regulations in effect prior to November 7, 1996, PTSD was rated under a general rating formula for psychoneurotic disorders. Under this formula, the Veteran’s currently assigned 50 percent rating was warranted for considerable impairment of the ability to establish maintain effective or favorable relationships with symptoms which reduced reliability, flexibility, and efficiency levels so as to result in considerable industrial impairment. A 70 percent rating was warranted for severe impairment of the ability to establish maintain effective or favorable relationships with symptoms of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. A 100 percent rating was warranted when the attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community, with totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic, and explosions of aggressive energy resulting in profound retreat from mature behavior with the demonstrative inability to obtain or retain employment. Prior to November 7, 1996, the Schedule for Rating Disabilities provided that the severity of a mental disorder was based upon actual symptomatology as it affected social and industrial adaptability. Two of the most important determinants of disability were time lost from gainful work and decrease in work efficiency. VA was not to under-evaluate the emotionally sick veteran with a good work record, nor was it to over-evaluate his or her condition on the basis of a poor work record not supported by the psychiatric disability picture. It was for that reason that great emphasis was placed upon the full report of the examiner, descriptive of actual symptomatology. The record of the history and complaints was only preliminary to the examination. The objective findings and the examiner’s analysis of the symptomatology were the essential considerations. The examiner’s classification of the disease as “mild,” “moderate,” or “severe” was not determinative of the degree of disability, but the report and the analysis of the symptomatology and the full consideration of the whole history by the rating agency would be. 38 C.F.R. § 4.130 (1996). In a precedent opinion, dated November 9, 1993, the General Counsel (GC) of the VA concluded that “definite” is to be construed as “distinct, unambiguous, and moderately large in degree.” It represented a degree of social and industrial inadaptability that was “more than moderate, but less than rather large.” VAOPGCPREC No. 93 (Nov. 9, 1993). The Board is bound by that interpretation of the term “definite.” 38 U.S.C. § 7104(c). Since November 7, 1996, all psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under this general rating formula, the Veteran’s current 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an 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 inability to establish and maintain effective relationships. A total schedular rating of 100 percent 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). During the pendency of this claim, the DSM-IV was superseded by a new fifth edition that significantly changed diagnostic metrics for mental illnesses. In pertinent part, the DSM-5 eliminated the Global Assessment Functioning (GAF) scores used in the DSM-IV. However, because this appeal was pending before the Board prior to August 4, 2014, the new regulations are inapplicable and the GAF scores are relevant evidence. 79 Fed. Reg. 45093 (August 4, 2014); see Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). The GAF score reflects the “psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness.” See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (4th ed.), p. 32.). Scores ranging from 61-70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally good functionality with meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score ranging from 31 to 40 indicates that there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A score ranging from 21 to 30 represents a person who demonstrates behavior that is considerably influenced by delusions or hallucinations or has serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation), or has the inability to function in most areas (e.g., stays in bed all day; no job, home, or friends). The Board notes that as many of the Veteran’s treatment records are in Spanish, where necessary the Board has obtained a translation of these records into English. The Veteran underwent a VA examination in February 1994. He reported that people tell him that he has done things that he does not remember. He reported intrusive memories and crying spells. His wife told him that he jumps from bed screaming at night. He reported episodes of aggression and violence as well as problems at work. He reported flashbacks, startle reactions, anxiety, nightmares, tremors, avoidance, and self-isolation. He stated that his nervous condition caused absenteeism at work. He reported “visions,” seeing and feeling the presence of “beings,” and strange sensations. The examiner observed that the Veteran was clean, adequately dressed, and groomed. He was alert and oriented. Mood was depressed and affect was blunted. Attention was good and concentration and memory were fair. Speech was clear, coherent, and soft. He became sad and tearful when discussing his service in Vietnam. He was not hallucinating and had no suicidal or homicidal ideation. Insight and judgment were fair. Impulse control was good. He was diagnosed with chronic paranoid schizophrenia with PTSD symptoms and assigned a GAF score of 45. At his May 1995 hearing related to his claim for service connection, the Veteran reported that his wife told him he screams during the night. He reported nightmares and flashbacks. He stated that sometimes his memories cause him to break down crying at his workplace. His wife reported that he is always nervous and is often in a bad mood and irritable. She reported that he has observed his constant nightmares. The Veteran underwent another VA examination in April 1996. He was examined by a board of three psychiatrists. He reported anxiety, crying spells, and irritability. The examiners noted a floating anxiety predominating over a referential ideation. Conversation was relevant, coherent, and well-organized. He was not hallucinating or delusional. Retention, recall, intellect, and sensorium were clear. Judgment was preserved. He was diagnosed with undifferentiated schizophrenia with PTSD symptoms and assigned a GAF score range of 61 to 70. VA treatment records reflect that in September 1996 the Veteran was admitted with an exacerbation of a mood, thought, and behavioral disorder. He reported increasing verbal aggression and hearing voices. He reported impulse control manifesting as a gambling problem. In October 1996 he was discharged from with continued outpatient treatment for PTSD with the aim to identify non-destructive ways to deal with aggressive behavior at home. In August 1997 he was hospitalized after a suicidal gesture and verbal/physical aggression towards his wife. He reported that he heard voices telling him to kill himself after drinking alcohol. He was diagnosed with rule-out alcohol dependence with paranoid schizophrenia by history and assigned a GAF score of 60. Private treatment records reflect that in August 2002 the Veteran reported emotional problems and a gambling problem. He was employed. He reported suicidal ideation with a plan to overdose. He reported that he attempted suicide by hanging three years prior. He reported auditory hallucinations. He reported anxiety, nightmares, restlessness, failure, fear, crying spells, sadness, concentration problems, panic attacks, self-isolation, paranoia, inability to work, difficulty making decisions, wanting to die, and aggression. His family reported that he became aggressive and violent, had memory issues, and sleep problems. He was diagnosed with recurrent severe major depression with psychosis and admitted for inpatient treatment. He was noted to have symptomatology and manifestations of behavior of significant severity that interfere with his social, vocational, and education functioning. In September 2002 he was discharged with diagnoses of bipolar disorder and depression with psychotic features. He was assigned a GAF score of 40 at an initial discharge in August 2002, and a GAF score of 65 at the subsequent September 2002 discharge. The Veteran was admitted again in October 2002 for one week to be treated for suicidal ideation. He was diagnosed with major depression with psychotic features and schizophrenic disorder depressive phase. He was assigned a GAF score of 25 on admission. He reported hallucinations telling him to kill himself. He reported a plan to jump from a bridge. On discharge he was diagnosed with severe major depression with psychotic features and assigned a GAF score of 40. VA treatment records reflect that in May 2004 the Veteran reported depression, sadness, anxiety, hostility, irritability, aggression, isolation, flashbacks, nightmares, and insomnia. He stated that he was currently employed. Mood was euthymic and affect was congruent with mood. He reported an auditory hallucination of a voice calling his name one week prior and visual hallucinations of shadows the prior night. He was fully oriented but reported episodes of spatial disorientation. Memory was intact. Judgment and insight were good. He reported one suicide attempt two years prior. He was diagnosed with psychosis, not otherwise specified and assigned a GAF score of 65. The Veteran underwent another VA examination in September 2004. He reported mild irritability with insomnia, inability to concentrate, mild anxiety, and mild tension over the prior year. He did not report frequent nightmares, intrusive thoughts, or avoidant behavior. He denied marital or family problems. Mood was euthymic and affect was constricted and appropriate. The examiner found that his signs and symptoms mildly interfered with employment functioning and social functioning. There was no impairment of thought process or communication and there was no inappropriate behavior. The examiner diagnosed residual schizophrenia and assigned a GAF score of 70. Specifically, the examiner noted some mild symptoms and some difficulty in social and occupational functioning but generally functioning pretty well with some meaningful interpersonal relationships. In a November 2004 statement, the Veteran reported tormenting nightmares and scarce sleep. He reported that he will not sleep in the dark. Private treatment records reflect that in November 2007 the Veteran reported anxiety and poor concentration. He was noted to have a constant preoccupation with past lives. He reported deterioration of mood, irritability, lowered concentration, anxiety, insomnia, and increased appetite. He denied suicidal ideation. He was diagnosed with moderate recurrent major depression and assigned a GAF score of 55. He was hospitalized for 5 days. VA treatment records reflect that in December 2007 the Veteran received medication for PTSD. His GAF score was 60. Private treatment records reflect that in January 2008 the Veteran reported sadness, insomnia, constant crying, anxiety, restlessness, delirium, loss of interest, poor appetite, poor concentration, poor energy, irritability, hallucinations, and formal disorders of thought. He reported hearing voices telling him to kill himself, and had thoughts of suicide through overdose. He reported homicidal ideation related to his coworkers. He was diagnosed with PTSD and paranoid schizophrenia and was admitted. He was subsequently diagnosed with recurrent severe major depression with psychosis, PTSD, and alcohol dependency, and was assigned a GAF score of 10. He reported depression, anxiety, and nightmares about war. He was discharged over a week later with a GAF score of 60. VA treatment records reflect that in January 2008 the Veteran reported that he had just been discharged from a private psychiatric hospital after completing inpatient treatment for acute exacerbation of depression and auditory hallucinations with resumption of alcohol drinking in the days prior to the onset of depression and psychotic symptoms. His discharge diagnoses were PTSD and recurrent major depressive disorder with psychotic features and alcohol dependence. His GAF score was 59. In July 2008 his GAF score was 58. In February 2009 he reported that he had been using his medication sporadically. He reported that his visual hallucinations persisted. The Veteran underwent another VA examination in March 2009. He reported social withdrawal, startle response, flashbacks, and nightmares. He reported that isolation and depression. He was currently employed. He had a close social circle of relatives and friends. He reported that he and his wife went shopping, went to the movies, played dominos, and went to the beach. Mood was anxious and labile. Affect was normal. Attention and orientation were intact. Thought process was unremarkable but content was preoccupied with one or two topics. There were no delusions, hallucinations, inappropriate behavior, panic attacks, or suicidal or homicidal thoughts. There was insomnia. Impulse control was fair. The examiner diagnosed PTSD productive of reduced reliability and productivity caused by severe social withdrawal. The examiner further diagnosed schizophrenia with PTSD symptoms overshadowing. The examiner noted severe symptoms of PTSD and assigned a GAF score of 58. The Veteran underwent a private psychological evaluation in December 2009. He reported episodes of losing control, becoming aggressive and violent, and having problems at work. He reported flashbacks, startle reaction, crying spells, disorientation, tremors, and nightmares. He stated that he avoids crowds, the forest, discussion of war, and television war scenes. He reported sleeping with lights on to feel secure. He was alert and oriented. Attention was good, affect was blunted, and he had difficulty concentrating. Memory was fair. Speech was clear, soft, and coherent. He denied recent suicidal or homicidal ideation. Insight and judgment were difficult. It was noted that although he was able to hold employment for many years, overall level of functioning was significantly impaired by his psychiatric symptoms. He had been severely disabled due to his symptoms since discharge, as was evident by his numerous hospitalizations and symptoms including poor impulse control to the point of physical and verbal assaults. The evaluator further noted that he was completely socially isolated and withdrawn even from his own family. He was diagnosed with PTSD and assigned a GAF score of 55. Private treatment records reflect that in June 2011 the reported irritability, hostility, discouragement, apathy, anhedonia, and occasional suicidal ideas. He was diagnosed with recurrent severe major depression with psychotic features, rule out PTSD. Later in the month he reported irritability, impulsivity, and frequent agitation. He was diagnosed with bipolar disorder. In July 2011 he reported a reduction of symptoms of irritability and impulsivity and a stable sleep pattern. He reported that he ignored his auditory and visual hallucinations. He reported a marked reduction in his symptoms in September 2011. In October 2011, he reported exacerbated symptoms, specifically, anguish, hopelessness, anxiety, and irritability. He reported persistent insomnia. In November 2011 he reported moderate depressive symptoms, with symptoms of anxiety and excitement greatly decreasing. He was diagnosed with mixed bipolar disorder without psychosis. VA treatment records reflect that in January 2012 the Veteran denied depression or suicidal ideation. He reported that he was sleeping well and was adjusting to retirement at the end of 2011. He reported continued hallucinations. He was alert, cooperative, and spontaneous. Mood was well with adequate affect. Thought content was without delusions. He was coherent, relevant, and logical. He was oriented to person, place, and time. Memory was preserved. Judgment and insight were fair. He was noted to have a history of diagnoses of major depressive disorder with psychotic features, alcohol dependence in early fully remission, and PTSD. He was assigned a GAF score of 60. Private treatment records include a March 2012 mental impairment evidence report. It describes the Veteran’s symptoms to include apathy, discouragement, weakness, anxiety, irritability, impulsivity, hostile behavior, aural hallucinations (murmurs), visual hallucinations (shadows), and occasional suicidal ideation without a plan. His psychiatrist noted continued severe symptoms of anxiety, depression, cognitive deterioration, and perceptual disturbances. He did not keep good visual contact, was uncommunicative, and exhibited frequent crying. His tone of voice was variable with periods of accelerated thought that was tangential and verbose. Mood was anxious and depressed. Affect was anxious. He exhibited recurring thoughts of death. He was oriented to person and place and partially oriented to time. Memory was poor. Intellectual functions were moderately deteriorated. Attention and concentration were poor. He reported social isolation and lack of motivation to do household tasks. His symptoms rendered him unable to complete a workday. Stress tolerance was poor. He was diagnosed with mixed bipolar disorder with psychotic features. He did not have the ability to handle his own funds. VA treatment records reflect that in May 2012 the Veteran reported feeling well and denied depression or suicidal and homicidal ideation. His wife came to his appointment with him. He reported that he was sleeping well. He reported that his hallucinations continued. He maintained his prior baseline. In July 2012 he reported doing well, usually in a good mood. He reported continued perceptual disturbances which he considered spiritual in nature and were endorsed by his church, thus not adversely affecting his functioning. He denied suicidal or homicidal ideation. He reported that his wife and children were his source of moral support. Mood was euthymic and affect was broad and congruent. Private treatment records reflect that in September 2012 the Veteran reported insomnia and frequent episodes of irritability and hostility. He was diagnosed with mixed bipolar disorder with psychotic features. He reported the same symptoms in February 2013 along with anxiety and hopelessness. VA treatment records reflect that in February 2013 the Veteran reported that he continued to do well, usually in a positive mood, remaining active in his church and spending time with his family. In May 2013 he reported paranoia, thinking that someone may be watching him or trying to poison him. It caused him anxiety, but he denied racing thoughts or hearing voices. He denied depression or grandiosity. His psychiatrist noted some paranoid overvalued ideas in absence of mood symptoms. He was prescribed medication. In August 2013 he reported feeling well without delusional beliefs, returning to his baseline of symptoms. He was diagnosed with major depressive disorder with psychotic features, rule out schizoaffective disorder. He was also diagnosed with alcohol dependence in full remission and PTSD by history. His GAF score was maintained at 60. In a December 2013 statement, the Veteran’s representative argued that a 100 percent evaluation was warranted for the entirety of the appeal period. VA treatment records reflect that in February 2015 the Veteran reported that suicidal thoughts were always present. In March 2015 he reported problems socializing with people and unusual sensory phenomena. He reported irritability and memory deficits. He denied suicidal ideation. He was diagnosed with an unspecified anxiety disorder, rule out PTSD. In April 2015 he reported feeling fine but had some depression. He was diagnosed with PTSD. In May 2015 he reported memory problems and stated that he sometimes feels as if there is a dead person behind him. Mood was depressed and affect was restricted. He reported intrusive memories and nightmares. In October 2015 he reported that he remained easily irritable at times. In December 2015 he and his wife reported that they were having marital problems. In January 2016 he reported continued intrusive memories and nightmares. In March 2016 he reported that his mood had been stable. He denied suicidal ideation. In September 2016 he reported recurrent nightmares about Vietnam, but the last one had been 2-3 weeks prior. In March 2017 he reported getting good sleep but a lack of energy. He stated that he thought he saw a woman in his kitchen but then determined that it was a “vision.” He had no recent auditory hallucinations. Thought process was linear, coherent, and goal oriented. He was fully oriented. Judgment and insight were fair. Remote memory was intact but he had some short-term memory difficulties. Affect was mildly constricted. In April 2017 his wife reported that he was experiencing flashbacks. In June 2017 his reported sensory experiences were attributed to delirium associated with severe kidney problems. Mood was better and affect remained mildly constricted. He was diagnosed with PTSD in partial remission. In July 2017 he reported that after going several weeks without medication he became more easily agitated and irritable with his family. He voiced no other mental health concerns. He was diagnosed with PTSD. VA treatment records further reflect that an August 2017 pre-surgical psychiatric consultation recommended against a kidney transplant for the Veteran based on psychological reasons. Among the reasons were cognitive functioning that was unable to be assessed, severe depression, severe anxiety, very severe symptoms of trauma, evidence of a bipolar spectrum disorder, visual hallucinations which may be suggestive of severe PTSD and/or psychosis, and poor understanding of the necessary requirements for pre- and post-op periods. Under examination, his mood was anxious and sad. Affect was flat. He reported current flashbacks and visual hallucinations. He denied current suicidal ideation. A September 2017 neuropsychological consultation noted mild nonspecific complaints about memory and diagnosed a mild unspecified neurocognitive disorder. Based on this, in October 2017 he was recommended with reservations for a kidney transplant, based on mild symptoms of anxiety and depression within the context of a past history of significant mental health symptoms. In an April 2018 statement, the Veteran reported that he began to work at a VA hospital in 1987. He stated that the medical director wished to fire him after he made an attempt on the life of a supervisor, but his psychiatrist and psychologist were opposed due to his condition. He reported that he experienced more violent episodes with his coworkers in 1999 leading to his hospitalization. He reported that due to his growing cognitive difficulties he was forced to retire in 2011. He reported that he still experiences nightmares. The record includes an April 2018 statement from the Veteran’s supervisor from 1988 to 2003. The supervisor stated that the Veteran was an average employee who did not go beyond but did enough to get by. His conduct was not very high due to his Vietnam flashbacks, and he was absent from work on sick leave more than the average employee due to his nervous condition. The supervisor stated that on occasion the Veteran attempted to hit an intermediate supervisor with a vacuum cleaner wand. The supervisor did not witness this but heard this story secondhand, and heard that the Veteran was almost suspended but charges were dropped. The Veteran has submitted a private psychological evaluation from April 2018. He reported frequent crying spells. He reported flashbacks that interfered with his prior employment. He reported that the job he held from 1987 to 2011 at the VA hospital was possible because he was receiving treatment from his workplace. His wife of 41 years was also present. She stated that he now barely sleeps at all and that she is unable to leave him alone due to concern about his history of suicidal ideation. She reported that he is irritable often. The psychiatrist diagnosed chronic severe PTSD and schizophrenia. The psychiatrist opined that the Veteran had been totally disabled and unable to work since he was dismissed from his job with the police department in 1984, though he was eventually able to work for VA only because VA provided a level of support that is not consistent with a typical workplace. The Board finds that a 70 percent evaluation is warranted for the Veteran’s mental health disability. For the period prior to November 7, 1996, this rating is warranted for severe impairment of the ability to establish maintain effective or favorable relationships with symptoms of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. For the period thereafter, this rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood. The Veteran’s symptomatology for the entirety of the appeal period meets these criteria. He has experienced multiple hospitalizations for suicidal ideation with a plan and in at least one case an attempt. He has consistently reported hallucinations which on occasion have instructed him to commit suicide. He has consistently reported cognitive difficulties, nightmares, anxiety, and irritability which occasionally has led to aggressive behavior. He has consistently reported flashbacks, crying spells, and avoidance related to the subject of Vietnam. The Board finds that these symptoms form a disability picture most accurately described by the criteria for the 70 percent evaluation. They have led to significant workplace difficulties and have been characterized as severe by multiple healthcare providers. For these reasons, the Board finds that a 70 percent evaluation is warranted for the Veteran’s mental health disability The Board further finds that an evaluation in excess of 70 percent is not warranted for the Veteran’s mental health disability. For the period prior to November 7, 1996, such a rating is available when the attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community, with totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic, and explosions of aggressive energy resulting in profound retreat from mature behavior with the demonstrative inability to obtain or retain employment. For the period after November 7, 1996, a higher rating is available for total occupational and social impairment. The evidence weighs against such manifestations. While the Veteran has experienced periods of hospitalization for exacerbation of symptoms, these periods are separated by long periods of relatively milder symptoms. His ability to maintain effective relationships with his family and to maintain employment for the bulk of the appeal period show that he is not totally occupationally impaired, nor is he demonstrably unable to maintain employment. While he certainly had extremely low GAF scores when he was admitted to the hospital, these scores invariably improved prior to discharge. His danger of self-harm cannot be characterized as persistent. His behavior is not grossly inappropriate. He has largely maintained orientation to time and place. He has maintained basic hygiene. His memory issues are relatively mild. While he has persistent hallucinations, treatment records indicate that aside from his hospitalizations he has managed them without major impact on his life, often interpreting them as spiritual experiences which he shared with his church. For these reasons, the Board finds that an evaluation in excess of 70 percent is not warranted for the Veteran’s mental health disability. 2. Entitlement to an effective date earlier than October 16, 1992, for an award of service connection for an acquired psychiatric disability, to include PTSD The Veteran seeks an effective date earlier than October 16, 1992, for an award of service connection for PTSD. Generally, the effective date of an award of a service connection claim, including a claim reopened after a final disallowance, is the date of receipt of a claim or the date entitlement arose, whichever is later. 38 U.S.C.A § 5110(a); 38 C.F.R. § 3.400. Under regulations applicable prior to March 24, 2015, any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim. An informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a) (2014). A reopened claim is any application for a benefit received after final disallowance of an earlier claim. 38 C.F.R. § 3.160(e) (2017). The effective date of an award of disability compensation based on a reopened claim under the provisions of 38 C.F.R. §§ 3.109, 3.156, 3.157, and 3.160(e) shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(r). If, however, the decision granting service connection was based on service treatment records in existence but not associated with the claims file at the time of the last final denial, the decision granting service connection is considered a reconsideration of the denial of the initial claim. 38 C.F.R. § 3.156(c). The Veteran initially filed a claim in February 1970 for service for a nervous condition. In May 1971 he received notification that his claim was denied. He did not appeal this decision nor did he submit any evidence during the one-year appeal period. The decision therefore became final. In March 1985 the Veteran filed a claim for a nonservice-connected pension based on his nervous condition. The claim was denied in a February 1986 rating decision. He filed a timely notice of disagreement in May 1986. A nonservice-connected pension was subsequently granted in an August 1988 Board decision. The Veteran next filed a claim for service connection on October 16, 1992. This claim was eventually granted in a July 2009 rating decision. It is the effective date assigned by this decision that the Veteran has appealed. In the Veteran’s January 2010 notice of disagreement and accompanying statement, his representative argued that in 1984 he filed a “claim for benefits due to a nervous condition.” The representative argued that VA only adjudicated the issue of entitlement to nonservice-connected pension without providing any notification as to why it did not grant service connection based on new evidence. In a December 2013 statement, the Veteran’s representative argued for an effective date of May 11, 1970, alleging that the service treatment records underlying the grant of service connection in the July 2009 rating decision were not part of the Veteran’s claims file at the time of the original May 1971 rating decision denying service connection for a nervous condition. The representative noted that no service treatment records were made available to the examiners in the June 1970 VA examination and the February 1994 VA examination. The Board notes that service treatment records contain pages date-stamped by VA with receipt dates from July 1970, soon after the Veteran’s initial claim. In light of this evidence, in a June 2018 statement the Veteran’s representative noted that it appears very likely that the service treatment records which had been previously argued qualified the Veteran for an effective date of May 11, 1970, were received by VA much earlier than the representative originally thought. As such, the representative argued for an effective date of March 27, 1985, based on the claim filed by the Veteran on that date. As an initial matter, the Board finds that the July 2009 rating decision did not rely on service treatment records which were not considered by the original May 1971 rating decision. To the extent that date stamps appear on the service treatment records, they establish that they were received by VA in July 1970. Furthermore, the May 1971 rating decision was based in part on a finding of no current mental health disability by the June 1970 VA examiner, a finding that does not turn on the presence of service treatment records. As such, the Board finds that the July 2009 rating decision did not rely on service treatment records which were not considered by the final May 1971 rating decision. The Board further finds that the Veteran did not submit a claim of service connection on March 27, 1985. The Veteran completed the nonservice-connected pension portion of the claims form. Under regulations governing at the time, an informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a) (1984). The March 1985 claim does not contain a request for service connection. Furthermore, when VA rightfully construed the claim as a claim for nonservice-connected pension and denied it, the Veteran through his representative filed an appeal. The representative presented argument in an April 1988 informal hearing presentation. At no time did the Veteran or his representative indicate that service connection was sought until he filed his claim on October 16, 1992. Tellingly, in filing this claim, the Veteran requested that his claim be reopened, indicating that he was not under any impression that he had an unresolved claim for service connection that had been filed earlier. For these reasons, the Board finds that subsequent to the final May 1971 rating decision, the Veteran did not file a claim to reopen until October 16, 1992. An earlier effective date for an award of service connection is therefore denied. 3. Entitlement to a TDIU The Veteran seeks a TDIU. He contends that his service-connected disabilities, when considered in combination, render him unemployable. He initially raised the issue of entitlement to a TDIU as a result of the increased rating claim on appeal in a June 2018 brief filed by his representative. As such, the determination as to whether he is entitled to a TDIU is part and parcel of the determination of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). The Board therefore has jurisdiction over this intertwined matter. Total disability means that there is present any impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. A substantially gainful occupation has been defined as “an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the Veteran’s earned annual income.” Faust v. West, 13 Vet. App. 342 (2000). When jobs are not realistically within his physical and mental capabilities, a veteran is determined unable to engage in a substantially gainful occupation. Moore v. Derwinski, 1 Vet. App. 356 (1991) (citing Timmerman v. Weinberger, 510 F.2d 439 (8th Cir. 1975)). In making this determination, consideration may be given to factors such as the veteran’s level of education, special training, and previous work experience, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A veteran is totally disabled if his service-connected disability or combination of service-connected disabilities is rated at 100 percent pursuant to the Schedule for Rating Disabilities. 38 C.F.R. § 3.340(a)(2). Even if a veteran is less than 100 percent disabled, he still is deemed totally disabled under the Schedule for Rating Disabilities if he satisfies two requirements. 38 C.F.R. § 4.16(a). First, the veteran must meet a minimum percent evaluation. If he has one service-connected disability, it must be evaluated at 60 percent or more. If he has two or more service-connected disabilities, at least one disability must be evaluated at 40 percent or more and the combined evaluation of all the disabilities must be 70 percent or more. The following will be considered as one disability with respect to the minimum percent evaluation: (1) disabilities of one or both upper extremities or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system (e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric), (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Second, the veteran must be found to be unable to secure and follow a substantially gainful occupation as a result of his service-connected disability or disabilities. Id. Where the veteran does not meet the percentage evaluation requirements under 4.16(a), he still may be deemed totally disabled on an extraschedular basis under 38 C.F.R. § 4.16(b) when the evidence nonetheless indicates that the veteran is unemployable by reason of his service-connected disabilities. Under such circumstance the matter is referred to the Director of the Compensation and Pension Service (“Director”) for consideration. Id.; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Extraschedular TDIU consideration requires contemplation of the following factors: severity of the Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). Although the Board does not have the authority to award an extraschedular TDIU prior to referral to the Director, the Board has jurisdiction to review and award extraschedular ratings in claims that have been denied by the Director. See Kuppamala v. McDonald, 27 Vet. App. 447 (2015). Under the regulations in effect prior to November 7, 1996, for TDIU, there existed a provision related to service-connected psychiatric disorders. Specifically, under 38 C.F.R. § 4.16(c), the provisions of schedular TDIU under 4.16(a) were not applicable in cases in which the only compensable service-connected disability is a mental disorder assigned a 70 percent rating, and such mental disorder precluded a Veteran from securing or following a substantially gainful occupation; in such cases, the mental disorder was assigned a 100 percent schedular rating. The fact that a veteran is in receipt of a combined schedular rating of 100 percent does not preclude the availability of a TDIU. Although no additional disability compensation may be paid when a total schedular rating is already in effect, a separate award of a TDIU predicated on a single disability may form the basis for an award of SMC, and thus must be considered by the Board. Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008). In determining whether a TDIU is warranted, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Because the Board herein grants the Veteran an evaluation of 70 percent for his mental health disability, he meets the threshold for a schedular TDIU under 38 C.F.R. § 4.16(a) for the entirety of the appeal period. For the entirety of the appeal period, the Veteran is service-connected for his PTSD. From May 2001, he is also service-connected for diabetes mellitus, along with associated neuropathies, circulatory insufficiencies, retinopathy, hypertension, and erectile dysfunction, effective various dates throughout the appeal period. The Board finds that prior to December 2011, the Veteran’s service-connected disabilities did not render him unemployable, as the Veteran’s statements and treatment records establish that he had a full-time job for this period. While it is true that the VA hospital at which the Veteran was employed made reasonable accommodations for his disabilities, the Board does not find that he was incapable of the work. Indeed, in his April 2018 statement, the Veteran described himself as a very responsible employee who always performed all his duties well. The fact that reasonable accommodations were necessary to allow him to perform his work is the equivalent of unemployability. For the period subsequent to December 2011, the Veteran is already in receipt of a combined schedular rating of 100 percent. As such, the Board need only consider whether the Veteran was rendered unemployable by a single service-connected disability. Bradley, 22 Vet. App. at 293-94. The Board therefore must determine whether the Veteran’s mental health disability alone rendered him unemployable for this period, as neither he nor his representative have provided evidence or argument indicating that any other service-connected disability alone rendered him unemployable. The Board finds that the Veteran’s mental health disability has not rendered him unemployable for the period since his retirement. Treatment records since that time have shown that, if anything, his symptoms have become milder. He has not been hospitalized for psychiatric reasons during this period. His treatment records focus on symptoms such as nightmares, irritability, and depression, with only occasional mentions of hallucinations. To the extent that his retirement was necessary for medical reasons, ample treatment records show that his deteriorating physical health was the clear impediment to employment for this period. For these reasons, the Board finds that the Veteran’s mental health disability has not rendered him totally unemployable for the period since his retirement. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Gallagher, Counsel