Citation Nr: 18145758 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 15-15 192 DATE: October 30, 2018 ORDER Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period prior to April 16, 2013, is denied. Entitlement to a disability rating of 50 percent, but no higher, for PTSD for the period from April 16, 2013, to April 15, 2015, is granted. Entitlement to a disability rating of 70 percent, but no higher, for PTSD for the period from April 16, 2015, to November 13, 2016, is granted. Entitlement to a disability rating in excess of 70 percent for PTSD for the period from November 14, 2016, onward, is denied. A total disability rating based on individual unemployability (TDIU) due specifically to the service-connected disability of PTSD from April 16, 2015, to November 13, 2016, is granted. A TDIU on a schedular basis, and referral for consideration of a TDIU on an extraschedular basis, due specifically to the service-connected disability of PTSD prior to April 16, 2015, is denied. FINDINGS OF FACT 1. For the period prior to April 16, 2013, the Veteran’s PTSD is not shown to have been productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 2. For the period from April 16, 2013, to April 15, 2015, the Veteran’s PTSD was productive of occupational and social impairment with reduced reliability and productivity; it is not shown to have been productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships). 3. For the period from April 16, 2013, to November 13, 2016, the Veteran’s PTSD was productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; it is not shown to have been productive of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 4. For the period from November 14, 2016, onward, the Veteran’s PTSD is not shown to have been productive of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 5. From April 16, 2015, to November 13, 2016, the Veteran has been rendered unable to secure or follow a substantially gainful occupation by his service-connected disability of PTSD rated 70 percent disabling. 6. Prior to April 16, 2015, the evidence does not support a finding that the Veteran’s PTSD (rated 50 percent or less disabling throughout) rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. For the period prior to April 16, 2013, the criteria for an initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411. 2. For the period from April 16, 2013, to April 15, 2015, the criteria for a rating of 50 percent (but no higher) for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411. 3. For the period from April 16, 2015, to November 13, 2016, the criteria for a rating of 70 percent (but no higher) for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411. 4. For the period from November 14, 2016, onward, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411. 5. The criteria for entitlement to a TDIU due to PTSD from April 16, 2015, to November 13, 2016, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 6. The criteria for entitlement to a TDIU on a schedular basis, or referral for consideration of a TDIU on an extraschedular basis, due to PTSD prior to April 16, 2015, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1971 to June 1973, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California, which granted entitlement to service connection for PTSD, effective from May 5, 2011, and assigned an initial 30 percent disability rating. During the pendency of this appeal, the RO issued a February 2017 rating decision that awarded an increased 70 percent disability rating for PTSD effective from November 14, 2016. Also during the pendency of this appeal, the Veteran raised the issue of entitlement to TDIU based upon his service-connected PTSD alone, and TDIU based upon his PTSD alone was granted for the period from November 14, 2016, onward, by the RO in an August 2017 rating decision. As explained below, the Board’s grants of increased ratings for PTSD in this case has significantly changed the premise of the scope of the RO’s grant of TDIU from November 2016, raising the need for the Board to consider further entitlement to TDIU based upon PTSD alone as part of this appeal. The Veteran testified at a Board hearing before the undersigned in June 2018. Increased Rating 1. Entitlement to an initial disability rating in excess of 30 percent for PTSD for the period prior to April 16, 2013, is denied. 2. Entitlement to a disability rating of 50 percent, but no higher, for PTSD for the period from April 16, 2013, to April 15, 2015, is granted. 3. Entitlement to a disability rating of 70 percent, but no higher, for PTSD for the period from April 16, 2015, to November 13, 2016, is granted. 4. Entitlement to a disability rating in excess of 70 percent for PTSD for the period from November 14, 2016, onward, is denied. The Veteran seeks an initial disability rating in excess of 30 percent for PTSD for the period prior to November 14, 2016, (the date upon which a 70 percent rating for his PTSD came into effect), and the Veteran seeks a disability rating in excess of 70 percent for PTSD for the period from November 14, 2016, onward. The appeal arises from the grant of service connection for PTSD which is effective from May 5, 2011, defining the beginning of the rating period on appeal. Disability ratings are determined by comparing a Veteran’s symptomatology during the pertinent period on appeal with criteria set forth in 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. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. With a claim for an increased initial rating (as in this case), separate “staged” ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Lay evidence may be competent to address any matter not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence pertinent to the issue on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating period on appeal to see if it supports a higher rating during the rating period on appeal. PTSD is rated by applying the criteria in 38 C.F.R. § 4.130, Diagnostic Code 9411. The VA Schedule rating formula for mental disorders reads in pertinent part as follows: 100 percent rating (the maximum schedular rating) - Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 70 percent - Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships). 50 percent - Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 30 percent - Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. VA had previously adopted the American Psychiatric Association: Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), for rating purposes. VA implemented DSM-5, effective August 4, 2014, and the VA Secretary determined that DSM-5 applies to claims certified to the Board on and after August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). As the Veteran’s increased rating claim was originally certified to the Board after August 4, 2014, DSM-5 applies in this case. DSM-IV, including its global assessment of functioning (GAF) scale, does not apply. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (a). The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). When determining the appropriate disability rating to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms; a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. An April 2011 VA mental health case management report shows that the Veteran was diagnosed with PTSD. His mental status examination revealed clean appearance with good grooming and hygiene, somewhat guarded but cooperative demeanor, anxious mood, restricted affect, and a denial of any “Suicidal/Homicidal/Assaultive Ideation/Intent/Plan.” The report shows a finding of no psychotic symptoms, and the Veteran’s thought process was “clear, coherent, logical,” with unremarkable thought content, no cognitive deficits, fair judgment, and fair insight.” The Veteran noted symptoms featured recurrent intrusive recollections, recurrent distressing dreams of event, acting or feeling event is recurring, intense distress at exposure to certain cues, efforts at avoidance, diminished interest in activities, feeling of detachment or estrangement, restricted range of affect, sense of foreshortened future, difficulty sleeping, irritability or outbursts of anger, and hypervigilance, exaggerated startle response. The report indicated that there was some associated “impairment in social/occupational/other areas.” An October 2012 VA PTSD psychiatric examination report documents a list of “all symptoms” associated with the Veteran’s PTSD. The Board notes that all of the Veteran’s mental health concerns were attributed to the PTSD diagnosis, with no mental health symptoms attributed to any other diagnosis. The VA examiner was informed by direct examination of the Veteran together with review of the claims-file. The October 2012 VA examination report shows that the Veteran’s symptoms at that time were: “Chronic sleep impairment,” and “Difficulty in establishing and maintaining effective work and social relationships.” The report also indicates that the Veteran’s PTSD manifested in recurrent and distressing recollections; recurrent distressing dreams; avoidance efforts; feelings of detachment or estrangement from others; restricted range of affect; difficulty falling or staying asleep; hypervigilance; and exaggerated startle response. The VA examiner expressly indicated that “No,” the Veteran did not have “any other symptoms attributable to PTSD (and other mental disorders) that are not listed above.” The VA examiner summarized the Veteran’s occupational and social impairment as: “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.” Notably, the VA examiner specifically chose a characterization of impairment that matches the language describing the level of impairment contemplated by a 30 percent rating in the applicable rating criteria. The Veteran’s April 2013 notice of disagreement includes the Veteran’s description of symptoms and impairment involving frequently thinking about his PTSD stressor, being unable to work around people, not having been employed since 1994 due to his psychiatric problems, flashbacks, feeling jumpy and being easily startled several times per week, extreme mood swings, having only one friend (who had been diagnosed with terminal cancer), losing his girlfriend due to an inability to manage his behavior due to PTSD, nightmares, and that he was unable to maintain any relationship with members of his own family. The Veteran described that his circumstances had left him “confused.” Mental health evaluation and treatment records from the Vet Center include a detailed August 2013 report indicating that the Veteran was experiencing symptoms featuring difficulty sleeping, mood problems, panic attacks several times per week, anxiety, and flashbacks 3 to 4 times per week. In June 2014, the Veteran submitted correspondence including the assertion that his PTSD is “much worse now.” In an April 2015 written statement, accompanying his VA Form 9 substantive appeal, the Veteran described being alienated from his family, experiencing suicidal thoughts, nightmares, flashbacks, panic attacks, severe mood swings, hallucinations, avoiding people, having no remaining friends, and that only a fear of jail prevented him from hurting his neighbors when they mock him. In November 2016, the Veteran underwent a new VA PTSD psychiatric examination for rating purposes. The November 2016 VA examination report presents the finding that the Veteran was suffering from: “Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.” The VA examiner found that this impairment was due to the Veteran’s PTSD together with his depression, but that the impairments from each diagnosis “overlap and are interrelated, therefore, it is not possible to differentiate what impairment is attributable to each diagnosis.” The VA examiner noted the following symptoms in connection with this assessment: depressed mood; anxiety; suspiciousness; panic attacks more than once a week, but not near-continuous panic or depression; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; impaired impulse control, such as unprovoked irritability with periods of violence; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The VA examiner additionally discussed that the Veteran “endorsed flashbacks, intrusive memories, irritability that does not extend to physical violence, socially avoidant behavior, hypervigilance, frequent anxiety, nightmares, worries and fearfulness.” The November 2016 VA examiner additionally noted that the Veteran “arrived on time and dressed appropriately for appointment.” The Veteran “showed restless demeanor and, initially appeared reticent.” The Veteran’s “mood was congruent with topics discussed,” and the Veteran “revealed logical and linear thought processes and he did not reveal any indication of psychosis.” The Veteran “showed a willingness to describe symptoms and appeared to become slightly more relaxed as he spoke. He appeared to put an effort into giving an honest account of his history and current symptoms.” Among the competent psychiatric examination evidence of record, it is significant that the thorough October 2012 VA rating examination report specifically indicates that the Veteran’s PTSD manifested in “[o]ccupational 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.” In choosing this characterization of the Veteran’s impairment, the VA examiner specifically declined to endorse a finding of greater impairment, and the absence of other selections on the report indicate that the VA examiner found that the Veteran’s PTSD did not manifest in “[o]ccupational and social impairment with reduced reliability and productivity” and did not manifest in “[o]ccupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.” The October 2012 VA psychologist’s assessment was informed by the Veteran’s own reporting of his symptom experience, clinical examination, and review of the claims-file; the October 2012 VA examination report is competent probative evidence weighing significantly against finding that the Veteran’s PTSD manifested in the level of impairment contemplated by the criteria for ratings in excess of 30 percent at that time. With consideration of all of the Veteran’s reported symptomatology, the competent VA examiner assessed that the Veteran’s resultant level of impairment was the level contemplated by a 30 percent rating, and no greater. The Board finds that there is no evidence persuasively contradicting the detailed findings of the October 2012 VA examination report or otherwise demonstrating the severity of PTSD impairment contemplated by a rating in excess of 30 percent at that time. Along similar lines, the November 2016 VA examination report is probative evidence supporting the already-assigned 70 percent rating for PTSD that is currently effective from the date of that examination. Thus, the Board finds that this evidence indicates that the severity of the Veteran’s PTSD significantly increased during the period between the October 2012 VA rating examination and the November 2016 VA rating examination. The Board has reviewed the evidence to determine whether it reasonably shows that the criteria for any rating in excess of 30 percent were met prior to November 2016. The Board notes that the October 2012 VA rating examination report showed that panic attacks were not part of the Veteran’s psychiatric symptom set, and it is thus notable that the Veteran reported panic attacks in his April 2013 statement, and he further specified panic attacks several times per week during his August 2013 Vet Center evaluation. The 2013 statements also described problems with mood and mood swings and anxiety that were not part of the symptom-set documented in the October 2012 VA rating examination report. Additionally, while the October 2012 VA rating examination report shows that the Veteran was in contact with his surviving siblings, his April 2013 statement described that he was no longer on good terms with his family. Also, the October 2012 VA rating examination report shows that the Veteran was in a long-term relationship with his girlfriend of 12 years, the April 2013 statement described that the relationship had recently ended due to behaviors associated with his problems coping with PTSD. The Board also notes that the Veteran’s June 2014 correspondence asserted that the severity of his PTSD symptomatology had progressed to become “much worse now,” further reflecting an ongoing progression of his PTSD impairment during this period. At the time of the Veteran’s April 2015 written statement, the Veteran’s description of his own symptoms newly reflected suicidal thoughts and suggestions of violent impulses towards other people. The Board observes that the Veteran had previously repeatedly denied suicidal thoughts, including as recently as in his August 2013 Vet Center evaluation. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the degree of impairment most nearly approximating the criteria for a 70 percent rating is sufficiently shown to have been present from as early as the Veteran’s written statement of April 16, 2015. Considering the degree of impairment established in the November 2016 VA examination report, the Board finds that the symptom report in the Veteran’s April 2015 written statement is credible and reasonably indicates that the progression of the Veteran’s PTSD impairment and symptomatology had approximated the level contemplated by a 70 percent rating as of that time. Accordingly, the Board finds that an increased 70 percent rating for PTSD is warranted for the period from April 16, 2015, to November 13, 2016. Significant symptoms such as suicidal thoughts and suggestions of violent impulses towards other people were not shown prior to April 2015. The Board finds that a level of impairment most nearly approximating that contemplated by the criteria for a 70 percent rating (or higher) is not shown prior to April 16, 2015. However, the Veteran’s PTSD symptomatology is reasonably shown to have worsened between the time of the October 2012 evidence showing the level of impairment approximating that contemplated by the criteria for a 30 percent rating and the time of the April 2015 evidence reasonably showing the level of impairment approximating that contemplated by the criteria for a 70 percent rating. The Board has carefully reviewed the evidence to determine the earliest date upon which impairment most nearly meeting the criteria for a 50 percent rating for PTSD are shown to have been met. The Board notes that the Veteran’s April 2013 statement and August 2013 Vet Center evaluation report indicate the presence of panic attacks (specified in the August 2013 report to be several times per week), problems with mood and mood swings, anxiety, the recent loss of his long-term relationship with his girlfriend due to his behavioral symptoms, and estrangement from his siblings that were not part of the symptom-set and impairment documented in the October 2012 VA rating examination report. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the evidence reasonably indicates that at the time of the Veteran’s April 16, 2013, statement, the shown progression of the Veteran’s PTSD impairment most nearly approximated occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, panic attacks more than once a week, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. Accordingly, the Board finds that an increased 50 percent rating for PTSD is warranted for the period from April 16, 2013, through April 15, 2015 (the day before the effective date upon which the Board finds that a higher 70 percent rating is warranted, discussed above). With regard to the period on appeal prior to April 16, 2013, the Board finds that there is no evidence of record that contradicts or revises the probative findings of the October 2012 VA examination report that most nearly approximate the level of impairment contemplated by the criteria for a 30 percent rating, and no higher. The Board finds that a level of impairment most nearly approximating that contemplated by the criteria for a rating in excess of 30 percent is not shown prior to April 16, 2015. Finally, with regard to the question of whether the Veteran’s PTSD has met the criteria for a 100 percent schedular rating, the Board finds that the evidence does not show a level of impairment most nearly approximating total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The Veteran’s testimony at his June 2018 Board hearing described that prior to November 2016 he was experiencing “nightmares, panic attacks,” in additional to difficulty with “personal relationships” and “coping” such that he was “not [able to] function that well.” The Veteran and his representative discussed that the Veteran’s “life was deteriorating to the point where there was suicidal tendencies.” The Board notes that the Veteran’s testimony regarding the severity of symptoms that manifested prior to November 2016 is consistent with the contemporaneous evidence of record, discussed above, and the Board’s analysis in this case results in the award of increased disability ratings for PTSD for periods prior to November 2016. The Board also notes that the Veteran’s presentation at the June 2018 Board hearing directed attention to his belief that an increase in the severity of his PTSD impairment was documented in the evidentiary record in April 2015, and the Board’s analysis of the evidence in this case has resulted in an award of an increased rating (from 30 percent to 70 percent) for the period beginning in April 2015. Furthermore, during the June 2018 Board hearing, the Veteran expressed concerns that certain GAF scores used in some of his medical records may misrepresent his level of impairment and unduly weigh against his claim. In this regard, the Board notes that its analysis in this case has focused upon the documented details of the Veteran’s symptoms and impairments independent of any GAF scores; no GAF score has been weighed against the Veteran’s claim in this decision. Additional references to the Veteran’s mental health are presented in other evidence of record, including reports from group therapy and individual counseling sessions associated with the Veteran’s treatment at times. The additional evidence of record does not present findings concerning the Veteran’s mental health that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. The Board finds that a 50 percent rating (increased from 30 percent) is warranted for the Veteran’s PTSD for the period from April 16, 2013, to April 15, 2015, and a 70 percent rating (increased from 30 percent) is warranted from April 16, 2015, to November 13, 2016. The Board finds that no further increased ratings are warranted for any periods on appeal. For the period prior to April 16, 2013, the evidence does not show mental health impairment featuring occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The evidence does not otherwise show symptoms of the nature and severity contemplated by the criteria for a rating in excess of 30 percent prior to April 16, 2013. For the period from April 16, 2013, to April 16, 2015, the evidence does not show occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships). The evidence does not otherwise show symptoms of the nature and severity contemplated by the criteria for a rating in excess of 50 percent for the period from April 16, 2013, to April 16, 2015. For the period from to April 16, 2015, onward, the evidence does not show total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The evidence does not otherwise show symptoms of the nature and severity contemplated by the criteria for a rating in excess of 70 percent for the period from April 16, 2015, onward. Not only does the evidence reflect that the Veteran’s PTSD did not manifest in the symptoms listed as examples for the criteria for increased ratings in these stages of the appeal period, but his psychiatric symptoms are not otherwise shown to have been of similar severity, frequency, and duration as contemplated by the criteria for higher ratings. See Vazquez-Claudio, 713 F.3d at 118. The Board finds that the Veteran’s disability picture, taken as a whole and in combination with the objective psychiatric examinations, has most nearly approximated the criteria for the ratings assigned by the Board in this decision at the pertinent periods for those assignments. The Board finds that the psychiatric disability picture has not manifested in such severity to warrant any additional or further increased ratings during any portions of the period on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). In reaching this conclusion, the Board has considered the benefit-of-the-doubt rule. However, as the preponderance of the evidence is against the award of further increased ratings, that doctrine is not applicable to this extent. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). In making the above determinations, the Board acknowledges that the use of the term “such as” in 38 C.F.R. § 4.130, Diagnostic Code 9411, demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board recognizes that there is no “formula” to follow when assigning ratings. Accordingly, the evidence considered in determining the level of impairment under Diagnostic Code 9411 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms associated with the Veteran’s PTSD that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV/5. Id. While particular symptoms associated with a higher rating may be present during pertinent portions of the appeal period, such symptoms are exemplars to aid in characterizing the degree of social and occupational impairment. Thus, while certain symptoms might be present on isolated occasions, such symptoms must produce the contemplated levels of occupational and social impairment to provide a basis for increased rating assignments in any particular period. The Veteran is competent to report lay-observable symptoms. The Board notes that the medical evidence in this case largely reflects that medical providers have accepted the Veteran’s descriptions of his own symptomatology, and the Board has accepted the competent symptom reports in this analysis. However, questions of assessing the degree of psychiatric functional impairment and identifying underlying features of psychiatric pathology involve medical questions beyond the capability of the Veteran’s own lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). There is no evidence to demonstrate the Veteran has the training and expertise to make psychiatric assessments of functional mental impairment from the complex combinations and patterns of symptomatology featured in this case. The Board has relied upon the competent medical evidence of record with regard to such medical assessments. TDIU Based Upon PTSD 5. A TDIU due specifically to the service-connected disability of PTSD from April 16, 2015, to November 13, 2016, is granted. 6. A TDIU on a schedular basis, and referral for consideration of a TDIU on an extraschedular basis, due specifically to the service-connected disability of PTSD prior to April 16, 2015, is denied. A claim for TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this appeal, the only disability for which a rating appeal has been properly within the Board’s jurisdiction is the Veteran’s PTSD. The Board need not consider any disability other than the service-connected PTSD in adjudicating the TDIU component of the Veteran’s claim for an increased disability rating for PTSD. This form of TDIU claim is known as a Rice TDIU, because it was raised during the administrative appeal of the Veteran’s claim for an increased rating for his service-connected PTSD and it is, therefore, a component of that claim for benefits related solely to that disability. See Rice v. Shinseki, 22 Vet. App. 447, 454-455 (2009). Such a claim is limited to the question of whether a veteran is unemployable exclusively due to the service-connected disability (or disabilities) on appeal. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is unable, by reason of his service-connected disabilities, to secure or follow a substantially gainful occupation consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. A threshold requirement for eligibility for a TDIU under 38 C.F.R. § 4.16(a) is that, if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of identifying one 60 percent disability, or one 40 percent disability in combination, disabilities resulting from common etiology will be considered as one disability. It is the policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation due to service connected disability shall be rated totally disabled. 38 C.F.R. § 4.16(b). Thus, if a Veteran fails to meet the schedular requirements above, an extraschedular rating is for consideration where the Veteran is nonetheless unemployable due to service connected disability. Id.; see also Fanning v. Brown, 4 Vet. App. 225 (1993). The Board may not grant a TDIU on an extraschedular basis in the first instance. Rather, the matter must be referred to the Director of the Compensation and Pension Service (Director) for extraschedular consideration. Bowling v. Principi, 15 Vet. App. 1, 10 (2001). The Veteran raised a claim of entitlement to a TDIU during the pendency of this appeal, including in March 2017 when he alleged that his PTSD had rendered him unemployable since 2006. The Veteran completed an application for TDIU in which he was asked: “What service-connected disability prevents you from securing or following any substantially gainful occupation?” The Veteran clearly and specifically replied: “PTSD.” The Board notes that the Veteran’s only other service-connected disability is tinnitus, and the Veteran did not suggest that his tinnitus was part of his claim of entitlement to TDIU. The RO arranged for a new VA mental health examination with medical opinion specifically for the purpose of assessing entitlement to a TDIU on the basis of the PTSD alone. In an August 2017 rating decision, the RO granted the Veteran’s claim of entitlement to TDIU due to PTSD effective from November 14, 2016; this was the same effective date as his 70 percent rating for PTSD (at the time of the RO adjudication) and the earliest date from which he met the schedular criteria for the TDIU (discussed below). The RO’s adjudication and grant of the Rice TDIU claim resolved the Rice TDIU claim to an extent, and the Veteran did not appeal for an earlier effective date for the TDIU award. However, the Board’s decision now results in an increase in the Veteran’s PTSD rating, of which the Rice TDIU claim was part-and-parcel, such that a 70 percent rating is now in effect for the earlier period of April 16, 2015; the Veteran now meets the schedular criteria for the Rice TDIU from April 16, 2015. The Board finds that the question of entitlement to a Rice TDIU based upon PTSD prior to November 14, 2016, has been raised such that the Board shall address the matter at this time. In accordance with the Board’s discussion of the PTSD rating assignments, above, the Board finds that the extent of the Veteran’s pertinent occupational impairment from April 16, 2015, to November 13, 2016, is essentially comparable to the extent of pertinent occupational impairment for the period beginning on November 14, 2016. Accordingly, as the RO has already established that the Veteran’s PTSD impairments were sufficient to qualify for TDIU as of November 14, 2016, the Board finds that a TDIU for the period from April 16, 2015, to November 13, 2016, is warranted. Also in accordance with the Board’s discussion of the PTSD rating assignments, above, the Board has determined that the Veteran’s PTSD manifested in impairment approximating occupational and social impairment with reduced reliability and productivity from April 16, 2013, to April 15, 2015. The Board has determined that the Veteran’s PTSD manifested in impairment approximating occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) for the period prior to April 16, 2013. In his March 2017 TDIU application, the Veteran reported that he had two years of college education, that he had worked at the Sacramento Army Depot as an electronic mechanic from 1973 to 1994. The Veteran reported that he hasn’t worked since that time, and reported that he left the job due to his PTSD. However, the Veteran also reported his disability did not affect his full-time employment until “06-15-2006,” and that the base that employed him closed in 1994. The October 2012 VA PTSD examination report shows that the Veteran reported that he “stopped working when [the base] closed” in 1994, and that he couldn’t get a job afterwards because he “couldn’t get along with people,” but that he “has had off jobs to make ends meet” and “looks for recyclable items when he walks and sells them.” The examination report showed that although the Veteran had difficulty with sleeping and in establishing and maintaining relationships, he had no manner of cognitive impairments, he did not have “[d]ifficulty in adapting to stressful circumstances, including work or a worklike setting,” and he was not unable to “establish and maintain effective relationships” (despite his “difficulty” in this area). The VA examiner found that the Veteran’s PTSD manifested in occupational impairment with “occasional decrease in work efficiency,” and “intermittent periods of inability to perform satisfactorily,” but not “reduced reliability and productivity,” and not “[t]otal occupational impairment.” The Board finds that the October 2012 VA PTSD examination report is competent and probative medical evidence indicating that the Veteran’s PTSD did not manifest in impairment rendering him unable to secure or follow a substantially gainful occupation consistent with his education and occupational experience. The Board finds that there is no contrary evidence that persuasively indicates that the Veteran’s PTSD impairments were of such severity as to render the Veteran unemployable for the period on appeal prior to April 16, 2013. Accordingly, referral for consideration of a TDIU on an extraschedular basis is not warranted with regard to that period. As discussed above, the Board has found that the Veteran’s PTSD increased in severity over time following the October 2012 VA PTSD examination. The Board has determined that the Veteran’s PTSD impairment is sufficiently shown to have approximated “[o]ccupational and social impairment with reduced reliability and productivity” from April 16, 2015, to November 13, 2016. The evidence supporting that increased rating, as discussed by the Board in the PTSD rating analysis above, shows some changes and increased impairments in the Veteran’s PTSD disability picture; however, none of the evidence pertaining to this period shows that the PTSD manifested in a degree of new impairments rendering him unable to secure or follow a substantially gainful occupation consistent with his education and occupational experience. Accordingly, referral for consideration of a TDIU on an extraschedular basis is not warranted with regard to that period. Prior to April 16, 2015, the Veteran does not meet the schedular criteria for TDIU when considering his PTSD alone. Further, given the competent evidence in this case, the Board finds that the preponderance of the evidence is against a finding that the Veteran was unable to secure and follow a substantially gainful occupation due solely to his service-connected PTSD for the periods prior to April 16, 2015. Accordingly, referral to the Director of Compensation for consideration of extraschedular TDIU prior to April 16, 2015, is not warranted. Conclusion In summary: (1) no increase in the assigned 30 percent rating is warranted for PTSD prior to April 16, 2013; (2) an increased 50 percent rating, but no higher, is warranted for PTSD from April 16, 2013, to April 15, 2015; (3) an increased 70 percent rating, but no higher, is warranted for PTSD from April 16, 2015, to November 13, 2016; (4) no increase in the assigned 70 percent rating is warranted for PTSD for the period from November 14, 2016, onward; (5) a TDIU due specifically to PTSD is warranted from April 16, 2015, to November 13, 2016; and (6) referral for consideration of an extraschedular TDIU due specifically to the service-connected disability of PTSD prior to April 16, 2015, is not warranted. Neither the Veteran nor his representative has raised any other issues associated with the PTSD ratings, nor have any other issues been reasonably raised by the record in connection with the PTSD rating. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Barone, Counsel