Citation Nr: 18147394 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 09-41 952 DATE: November 5, 2018 ORDER 1. Entitlement to service connection for a lumbar spine disability, to include as secondary to service-connected left knee disabilities, is denied. 2. Entitlement to service connection for a right knee disability, to include as secondary to service-connected left knee disabilities, is denied. 3. Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to October 17, 2012, is denied. 4. Entitlement to an evaluation in excess of 50 percent for PTSD from October 17, 2012, to February 27, 2017, is denied. 5. Entitlement to an evaluation in excess of 70 percent for PTSD from February 27, 2017. 6. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. A chronic lumbar spine disability did not have its onset during active service or within one year of service discharge, is not otherwise related to active service, and is not caused or aggravated by service-connected left knee disabilities. 2. A chronic right knee disability did not have its onset during active service or within one year of service discharge, is not otherwise related to active service, and is not caused or aggravated by service-connected left knee disabilities. 3. Prior to October 17, 2012, PTSD was not manifested by occupational and social impairment with reduced reliability and productivity. 4. From October 17, 2012 to February 27, 2017, PTSD was not manifested by occupational and social impairment with deficiencies in most areas. 5. From February 27, 2017, PTSD has not been manifested by total occupational and social impairment. 6. The Veteran has not been precluded from securing or following a substantially gainful occupation due to service-connected disabilities for any period on appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbar spine disability, to include as secondary to service-connected left knee disabilities, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for service connection for a right knee disability, to include as secondary to service-connected left knee disabilities, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria for an increased disability rating for PTSD in excess of 30 percent prior to October 17, 2012, in excess of 50 percent from October 17, 2012, and in excess of 70 percent from February 27, 2017 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). 4. The criteria for a TDIU rating have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from April 1986 to December 1991. These matters were most recently remanded by the Board in October 2014 for additional development, including medical opinions regarding the Veteran’s service connection claims that addressed a secondary theory of service connection, as well as a retrospective medical opinion regarding the symptomatology and severity of the Veteran’s service-connected PTSD throughout the pendency of the appeal. As the requested development has been completed, the matters are properly returned to the Board for adjudication. To the extent that additional evidence has been associated with the claims file since the most recent March 2017 supplemental statement of the case (SSOC), the Veteran’s attorney provided a waiver of initial consideration of such evidence by the Agency of Original Jurisdiction (AOJ) in August 2018; therefore, it has been properly considered by the Board herein. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. For certain chronic disorders, including arthritis, service connection may be granted on a presumptive basis if the disease is manifested to a compensable degree within one year following service discharge. Additionally, for such chronic diseases shown in service or by a continuity of symptoms after service, the disease shall be presumed to have been incurred in service. Even where service connection cannot be presumed, service connection may still be established on a direct basis. 1. Entitlement to service connection for a lumbar spine disability, to include as secondary to service-connected left knee disabilities. The Veteran claims that is current lumbar spine disability is related to service or caused or aggravated by his service-connected left knee disabilities (the Veteran has separate ratings for limitation of motion of the left knee and instability of the left knee). As to evidence of a current disability, post-service treatment records document diagnostic x-rays that showed degenerative changes of the lumbar spine at L5-S1. Thus, the first element of a service connection claim is met. Regarding the second element of a service connection claim, an in-service disease or injury, service treatment records document a complaint of back pain in May 1986, which was one month after service entrance. At that time, the Veteran denied a history of direct back trauma in the past 72 hours. Thus, there is a complaint of back pain while the Veteran was in service. As to evidence of a nexus between the current disability and service, the Board finds that the preponderance of the evidence is against a nexus. For example, a November 1991 separation examination documents a normal clinical evaluation of the Veteran’s spine without noted defects or diagnosis. In the concurrent Report of Medical History, the Veteran denied a history of recurrent back pain and denied an illness or injury other than what was already noted on the form. The normal clinical evaluation of the spine and the denial by the Veteran of recurrent back pain at service discharge tends to show that the Veteran’s complaint of back pain in May 1986 was an isolated incident without recurrent back pain. In March 2010, a VA examiner opined that the Veteran’s current low back pain was not related to service but was related to his age, vocation, and lifestyle following his active service. Similarly, in September 2013, although the Veteran reported that his back was injured in 1988 while carrying an antenna up a hill on base, the examiner ultimately opined that the Veteran’s claimed back condition was less likely than not related to active service. The examiner noted that there was no documented back injury in 1988 within service treatment records and found that there was a lack of evidence in the service treatment records of chronicity of symptoms. The lack of chronicity of back problems in service is supported by the Veteran’s denial at service discharge of recurrent back pain and of having an illness or injury other than those noted on that form and the normal clinical evaluation of the spine at that time. The September 2013 examiner opined that degenerative disc disease (DDD) of the lumbar spine was associated with tobacco use and continued use of tobacco, advancing age, and normal wear and tear on the lumbar spine. He added that the Veteran’s physically demanding occupational history following active service, including construction work, frame work, plant line work, and as a forklift driver also contributed to the lumbar spine disability. As to secondary service connection, the Board also finds that the preponderance of evidence weighs against a finding of a nexus between the Veteran’s current lumbar spine disability and his service-connected left knee disabilities. Although a February 2010 VA examiner was unable to opine whether the Veteran’s lumbar spine disability was secondary to his left knee disability without resorting to mere speculation, in July 2016, a different VA examiner opined that the Veteran’s lumbar spine disability was not at least a likely as not proximately due to or the result of his service-connected left knee disabilities. The July 2016 VA examiner noted that such a claim was not supported by current medical literature, which showed that issues of a weight-bearing joint do not affect the lumbar spine unless there is a severe change in gait, or a significant leg discrepancy, which the examiner wrote the Veteran did not have. Rather, the examiner concluded that the Veteran’s current lumbar spine issues with degenerative disc disease were attributable to age, normal wear and tear on joints, being overweight, and his history of tobacco use. This probative opinion is evidence against a finding that the Veteran’s service-connected left knee disabilities caused or aggravated his current lumbar spine disability. To the extent that the Veteran has asserted that his current lumbar spine disability had its onset during active service or is otherwise related to active service, to include his service-connected left knee disabilities, the Board finds that his reports of an in-service onset of a chronic lumbar spine disability are inconsistent with and unsupported by the service treatment records, which document an isolated complaint of back pain in May 1986 followed by a normal separation examination and with a specific denial of recurrent back pain by the Veteran at service discharge in 1991. The Board accords more probative value to the Veteran’s denial of recurrent back pain as service discharge, as he completed this form contemporaneously with service. As such, the Veteran’s contentions of chronic back pain that started in service are not credible. Additionally, the Veteran lacks the medical expertise to render a nexus opinion that links his current lumbar spine disability to active service and to his service-connected left knee disabilities; therefore, his statements in this regard are of no probative value. As such, the Board finds that the preponderance of the evidence is against a finding that the current lumbar spine disability had its onset during active service or that it is otherwise related to active service or secondary to the service-connected left knee disabilities. As the preponderance of evidence weighs against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim is denied. 2. Entitlement to service connection for a right knee disability, to include as secondary to service-connected left knee disabilities. The Veteran also claims entitlement to service connection for a right knee disability, to include as secondary to the service-connected left knee disabilities. As to evidence of a current disability, post-service treatment records document right knee arthralgia, osteoarthritis, knee strain, patellofemoral pain syndrome, and eventual right total knee replacement. Thus, the first element of a service connection claim is met. Regarding the second element of a service connection claim, service treatment records document right knee pain following a basketball injury in July 1988, which was assessed later that month as mild tendonitis. Thus, there is evidence of an in-service disease or injury. However, the preponderance of the evidence is against a nexus between the post service right knee disability and service. Following the 1988 injury, a November 1991 Report of Medical Examination shows that clinical evaluation of the lower extremities was normal without noted defects or diagnosis. Additionally, in the Report of Medical History that the Veteran completed at that time, he specifically denied “‘Trick’ or locked knee” and denied an illness or injury other than those already noted. Thus, this tends to show that the 1988 complaint of right knee pain did not develop into a chronic right knee disability in service since the Veteran denied knee problems at service discharge in 1991. Moreover, there are negative nexus opinions that weigh against the theory of direct service connection. Upon VA examination in March 2009, the Veteran reported that his knee pain began following a basketball injury in 1988. The VA examiner subsequently opined that the Veteran’s current right knee problems were related to a gunshot wound to his right knee in 2008, although the examiner stated that it would be mere speculation as to whether a reported in-service right knee strain in 1988 would cause any problems at the time of examination. Upon subsequent VA examination in September 2013, the Veteran reported that during active service in 1988, he was hit with an oak stick in his right knee, which required treatment with pain medication and bedrest. The examiner acknowledged the Veteran’s in-service treatment of right knee pain, which he wrote had resolved by separation and ultimately opined that the claimed right knee condition was less likely than not related to active service. Rather, the examiner concluded that the Veteran’s advanced right knee osteoarthrosis and degenerative changes were associated with his history of a gunshot wound to right knee in 2008. As to secondary service connection, the Board also finds that the preponderance of evidence weighs against a finding of a nexus between the Veteran’s current right knee disability and his service-connected left knee disabilities. In July 2016, a VA examiner opined that the Veteran’s right knee disability was not at least a likely as not proximately due to or the result of the service-connected left knee disabilities. The July 2016 VA examiner noted that such a claim was not supported by current medical literature, which showed that issues of one weight bearing joint do not progress or lead to degenerative changes of a weight bearing joint on the opposite of the body. Rather, the examiner concluded that the Veteran’s current right knee disability was attributable to age, normal wear and tear on joints, being overweight, and his history of tobacco use. This probative opinion is evidence against a finding that the Veteran’s service-connected left knee disability caused or aggravated his current right knee disability. To the extent that the Veteran has asserted that his current right knee disability had its onset during active service or is otherwise related to active service, or to his service-connected left knee disabilities, the Board finds that his reports of an in-service onset of a chronic right knee disability are inconsistent with and unsupported by the service treatment records, which document an isolated complaint of right knee pain in July 1988 (not an injury after being struck by a stick as reported by the Veteran in September 2013) followed by a normal separation examination with a specific denial of knee complaints at service discharge by the Veteran. The Board accords more probative value to the Veteran’s denial of knee problems at separation, as he completed the Report of Medical History contemporaneously with service. As such, the Veteran’s contentions of chronic right knee pain that started in service are not credible. Additionally, the Veteran lacks the medical expertise to render a nexus opinion that links his current right knee disability to active service, including his service-connected left knee disability; therefore, his statements in this regard are also of no probative value. For the above reasons, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s current right knee disability had its onset during active service, that it manifested to a compensable degree within one year following service discharge, is otherwise related to active service, or is secondary to his service-connected left knee disabilities. As the preponderance of evidence weighs against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim is denied. 3. Entitlement to an increased disability rating for PTSD in excess of 30 percent prior to October 17, 2012, in excess of 50 percent from October 17, 2012, and in excess of 70 percent from February 27, 2017. Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. With respect to the Veteran’s increased rating claim on appeal, the Board has considered his claim from one year prior to his September 2006 increased rating claim, as well the appropriateness of the assigned staged ratings periods. The Veteran’s service-connected PTSD is currently rated as 30 percent disabling prior to October 17, 2012, 50 percent disabling from October 17, 2012, and 70 percent disabling from February 27, 2017 under Diagnostic Code (DC) 9411 of the General Rating Formula for Mental Disorders. Under the applicable rating criteria, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when there is 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. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals, which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Finally, a 100 percent disability rating is warranted when there is 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. When determining the appropriate disability evaluation 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. 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, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. 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. As discussed below, following a review of the evidence of record, the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to an increased disability rating for PTSD in excess of 30 percent prior to October 17, 2012, in excess of 50 percent from October 17, 2012, and in excess of 70 percent from February 27, 2017. The Board will address each evaluation separately and explain why it finds that higher ratings are not warranted for each stage. I. Prior to October 17, 2012. First, the Board concludes that the preponderance of evidence weighs against a disability rating in excess of 30 percent for PTSD prior to October 17, 2012. VA treatment records from August 2006 document a hospital admission for “homicidal ideation” after a man hit the Veteran in the face with a brick, apparently in a drug and alcohol related altercation. Notably, the Veteran did not have any current symptoms of PTSD at the time and was not taking any related medication for PTSD. Additional treatment records from August and September 2006 reiterate that, although the Veteran was undergoing treatment for substance abuse, he had no symptoms of PTSD at that time. Similarly, in August 2007, the Veteran checked himself into a VA Medical Center for a drug detoxification program. Upon admission, the Veteran presented with normal thought process, memory, concentration, and orientation, with poor judgment in that he continued to use alcohol and drugs; however, there were no delusions, hallucinations, obsessions, suicidal thoughts, or aggressive thoughts. The Veteran reported his prior diagnosis of PTSD; however, his Axis I diagnosis both at admission and discharge was noted as cocaine and alcohol dependence and to rule out substance-induced dysphoria. In January 2008, the Veteran was admitted to the hospital after admitting that he felt he was going to commit a violent act against a person who shot him in the ankle two months before. The Veteran reported cold sweats, anxiety, trembling, nightmares, and flashbacks. The physician indicated that the Veteran had a depressed affect and mood, although his thoughts, memory, and concentration were normal, with good insight, and without suicidal ideation, mania, psychosis, or hallucinations. His diagnoses included cocaine abuse, alcohol abuse, PTSD, and depression. The following day, the examiner wrote that the Veteran did not appear to be depressed, anxious, aggressive, or troubled, and he denied experiencing anxiety or physical symptoms of PTSD. His Axis I diagnoses included cocaine and alcohol dependence, but did not include PTSD. A treatment record from two days later reflects that once the effects of the Veteran’s drug use had been removed, medical treatment could be considered for “what seems like PTSD with comorbid depression.” An April 2008 private psychological report indicates that the Veteran appeared alert, oriented, and cooperative, with logical and coherent thought processes, normal speech, intact memory, satisfactory judgment and insight, with normal grooming and hygiene. The private physician diagnosed depressive disorder not otherwise specified; alcohol dependence; history of cocaine dependence; and rule-out PTSD. VA treatment records from September 2008 document that the Veteran was again hospitalized after a fight with his nephew over his attempt to collect drug money debt. The Veteran reported ongoing alcohol and cocaine use. Upon mental status examination, he appeared with a normal mood, thought processes, memory, concentration, and orientation, with fair insight and judgment, and without any delusions, hallucinations, obsessions, or suicidal thoughts, though he reported aggressive thoughts. The physician diagnosed depression, not otherwise specified, PTSD, alcohol dependence, and cocaine dependence. In February 2009, the Veteran appeared moderately anxious, with logical and coherent thoughts, neat dress and grooming, and without suicidal or homicidal ideation, hallucinations or delusions. Similar mental status examination findings were noted within VA treatment records spanning from April 2009 to March 2010. In April 2010, the Veteran reported that he was doing okay in school and he denied drug or alcohol abuse. In May 2010 and October 2010, the Veteran appeared motivated for continued recovery and reported doing well. He reported some increased stress from having his daughter live with him, but noted things were good and he was in the process of moving to a larger apartment. He continued to attend school and maintained contact with his siblings, who were a support to him. In March 2011, the Veteran reported a DUI and relapse with drinking in December 2010, but denied further issues with alcohol or drugs. In March 2012, he reported increased alcohol use, paranoid thoughts, irritability, and anxiety, though he denied suicidal or homicidal ideation and hallucinations. The Veteran noted that he had been evacuated from his home after a tornado and was currently living in a FEMA trailer and attending school. He appeared mildly anxious with normal speech, increased paranoia with drinking, intact memory and concentration, and fair insight and judgment. Notably, the Board previously found that such evidence suggested that while the Veteran was experiencing some symptoms attributable to PTSD prior to October 17, 2012, the majority of his symptoms that were indicative of an increased disability rating were due to ongoing nonservice-connected substance abuse. Within a July 2014 Joint Motion for Partial Remand (JMPR), the parties agreed that it was not clear that the medical evidence clearly distinguished the Veteran’s PTSD symptoms from his nonservice-connected psychiatric conditions, including substance abuse. As such, parties determined that the Board’s finding was an impermissible medical conclusion. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board is also mindful that when it is not possible to separate the effects of a service-connected disability and a nonservice-connected disability, reasonable doubt must be resolved in the Veteran’s favor and the symptoms in question attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Therefore, following the October 2014 Board remand, a retrospective medical opinion was obtained in February 2017. At that time, a VA examiner noted that a review of the Veteran’s medical records since 2006 to current indicated a long history of psychiatric admissions, primarily for alcohol-use difficulties. In particular, the examiner noted that the Veteran’s 2008 hospitalization appeared to be due to homicidal ideation after being shot a couple of months prior by another man; however, he was also treated for substance abuse at that time. Thus, the examiner concluded that the Veteran’s difficulties at the time were occurring in the context of substance abuse problems, and it was not clear that his PTSD symptoms played a prominent role in that hospitalization. Additionally, the examiner noted that since that time, given the Veteran’s long history of substance abuse, it was difficult to determine the exact extent and impact of his PTSD on his functional limitations. However, the examiner concluded that it was most likely that the Veteran’s substance abuse contributed significantly to his functional difficulties. The examiner noted that the Veteran’s social functioning appeared to be impacted by both his PTSD and Alcohol Use Disorder in that he lacked friends and was unable to develop a long-term romantic relationship; additionally, his occupational functioning was also impacted, as he had been fired from multiple jobs due to an inability to get along with others, though the examiner noted that when he was sober, he was able to complete educational degrees in social work. The Board finds that the February 2017 retrospective opinion is highly probative regarding the severity of the Veteran’s PTSD symptomatology prior to October 17, 2012, as it was based on a thorough review of the record and the examiner distinguished between the Veteran’s service-connected PTSD and his nonservice-connected substance abuse. The examiner concluded that the Veteran’s 2008 hospitalization and difficulties at the time occurred in the context of his nonservice-connected substance abuse problems, and it was not clear that his PTSD symptoms played a prominent role in that hospitalization. Additionally, the examiner concluded that it was most likely that the Veteran’s substance abuse contributed significantly to his functional impairment. Given the above, the Board concludes that while the record prior to October 17, 2012 documents some impairment resulting from the Veteran’s service-connected PTSD, the preponderance of evidence is against a finding that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity for the period prior to October 17, 2012. In making this determination, the Board has also taken into account the Veteran’s varying Global Assessment of Functioning (GAF) scores (from a low of 25 in August 2006 to 60 in October 2009 to March 2011), as his appeal was certified to the Board prior to August 4, 2014. See Golden v. Shulkin, 29 Vet. App. 589 (2018). However, the Board ultimately places more probative value on the objective and narrative findings discussed above regarding the Veteran’s psychiatric symptomatology, which are far more descriptive (and therefore of more probative value) than the numerical GAF scores. The Board notes that the use of the GAF scale has been abandoned in the DSM-5 because of, among other reasons, “its conceptual lack of clarity” and “questionable psychometrics in routine practice.” See DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fifth edition, p. 16 (2013). This is another basis to accord more probative value to the specific clinical findings made by the examiner while observing the Veteran during the examination than to the GAF scores. As the Veteran’s PTSD symptoms do not meet the rating criteria for a higher 50 percent disability rating prior to October 17, 2012, it follows that his PTSD symptoms also do not meet the more severe rating criteria for an increased 70 or 100 percent disability rating prior to October 17, 2012. Significantly, he has not shown the required severity of occupational and social impairment necessary for an increased 70 or 100 percent disability rating during the rating period, and his symptoms as a whole are not of similar severity, frequency, and duration as those particular symptoms associated with a 70 or 100 percent disability rating. In conclusion, the preponderance of the evidence is against the Veteran’s claim of entitlement to an increased disability rating in excess of 30 percent for PTSD prior to October 17, 2012, as his PTSD is not more closely approximated by occupational and social impairment with reduced reliability and productivity. As the preponderance of the evidence is against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim is denied. II. From October 17, 2012 to February 27, 2017. Upon VA examination on October 17, 2012, the examiner noted the Veteran’s psychiatric symptoms, including depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and impaired impulse control. The examiner distinguished that the Veteran’s impaired judgment and impulse control were attributable to his nonservice-connected alcohol abuse, while his other symptoms were attributable to service-connected PTSD. Additionally, the examiner concluded that the Veteran experienced occupation 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 due to his nonservice-connected alcohol abuse, and occupational and social impairment with reduced reliability and productivity due to his service-connected PTSD. Additionally, the examiner assigned a GAF score of 50 due to low social tolerance, aggression, and having few friends. The examiner also stated that the Veteran’s PTSD impeded employment due to reduced concentration, thought organization, and anger control, but found it did not preclude employment. Additional VA treatment records during the rating period from October 17, 2012 to February 27, 2017 document the Veteran’s ongoing psychiatric treatment for both service-connected PTSD and nonservice-connected substance abuse disorders. The Veteran attended both individual and group therapy sessions; additionally, the Veteran received additional inpatient treatment for repeated substance abuse relapses. As such, the Board finds that for the period from October 17, 2012 to February 27, 2017, the preponderance of evidence weighs against an increased disability rating in excess of 50 percent for PTSD, as the Veteran’s PTSD symptomatology does not more closely approximate occupational and social impairment with deficiencies in most areas. The probative evidence during the rating period does not document suicidal ideation; obsessional rituals, which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; or neglect of personal appearance and hygiene or other symptoms of this level of severity. While the objective evidence documents symptoms of irritability and anger, the Board finds it probative that the October 2012 VA examiner attributed impaired judgment and impulse control to the Veteran’s nonservice-connected alcohol abuse. Additionally, the Board is mindful that the October 2012 VA examiner specifically identified that the Veteran’s occupational and social impairment met the criteria for a 50 percent disability rating. While the adjudicator is responsible in determining, which disability rating is warranted, the VA examiner’s conclusion that the Veteran’s impairment resulting from his service-connected PTSD is best described as meeting the 50 percent disability rating criteria is evidence against a finding that the Veteran’s service-connected PTSD results in occupational and social impairment with deficiencies in most areas during the rating period. Finally, the Board notes that the October 2012 VA examiner documented a GAF score of 50, which indicates severe symptoms in the DSM-IV. The examiner stated that the assigned GAF score reflected the Veteran’s social isolation (a symptom associated by the examiner with the Veteran’s service-connected PTSD) as well as his aggression (a symptom associated by the examiner with his nonservice-connected alcohol abuse); therefore, the Board affords this isolated numerical GAF score less probative value in the context of the Veteran’s claim than the objective and narrative findings of the October 2012 VA examiner. As the Veteran’s PTSD symptoms do not meet the rating criteria for a higher 70 percent disability rating for the rating period from October 17, 2012 to February 27, 2017, it follows that his PTSD symptoms also do not meet the more severe rating criteria for an increased 100 percent disability rating for the rating period. Significantly, he has not shown the required severity of occupational and social impairment necessary for an increased 70 or 100 percent disability rating during the rating period, and his symptoms as a whole are not of similar severity, frequency, and duration as those particular symptoms associated with a 70 or 100 percent disability rating. In conclusion, the preponderance of the evidence is against the Veteran’s claim of entitlement to an increased disability rating in excess of 50 percent for PTSD from October 17, 2012 and prior to February 27, 2017, as his PTSD is not more closely approximated by occupational and social impairment with deficiencies in most areas. As the preponderance of the evidence is against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. III. From February 27, 2017. Upon VA examination on February 27, 2017, the VA examiner diagnosed PTSD and alcohol use disorder, with symptoms including depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; and impaired impulse control, such as unprovoked irritability with periods of violence. While the examiner checked a box indicating that it was not possible to differentiate the Veteran’s psychiatric symptoms between his diagnoses, as both could lead to difficulties with mood, behavior, and sleep, the Board finds it probative that the examiner concluded that the Veteran’s alcohol use contributed significantly to his resulting occupational and social impairment with deficiencies in most areas. In support of this, the examiner noted that the Veteran was able to complete two college degrees when he was sober, and that his admissions for inpatient psychiatric care were primarily due to his alcohol use disorder. The Veteran reported that he remained in contact with one of his two daughters and her mother and though he lacked friends, he went to the gym for recreation. Regarding employment, the Veteran reported working at 10 to 20 different places, mostly at production and warehouse positions, and stated that he left or was fired due to an inability to get along with others. Upon mental status examination, the Veteran appeared alert and oriented, with appropriate grooming and hygiene, fair attention and concentration, normal speech and thought content, with good insight, judgment, and competence to manage his financial affairs. Subsequent VA treatment records document ongoing treatment for PTSD, as well as substance abuse. In February 2017, the Veteran was admitted for inpatient substance abuse treatment. At the time of his discharge in March 2017, he appeared alert and oriented, with normal appearance, motor activity, mood, speech, thought processes, memory, insight, and judgment, and without delusions, hallucinations, suicidal or homicidal ideation, or obsessive/compulsive behaviors. The physician noted that during the Veteran’s 14-day residential rehabilitation stay, he did not report suicidal or homicidal ideation or display behavior indicative of being a danger to himself or to others. The Veteran reported vague suicidal ideation before his admission to the hospital in February 2017, but denied any current thoughts and noted support from his children and his religious belief. In April 2018, a VA examiner wrote that the Veteran’s PTSD was “stable.” That same month, the Veteran expressed his desire to find full-time employment and inquired about returning to his transitional work site through his VA vocational rehabilitation program. Upon mental status examination, he appeared alert, oriented, and cooperative, with clear speech, normal thought processes and content, with good judgment and insight. He denied suicidal or homicidal ideation and noted that his mood and anxiety had been fine and he was working on controlling his anger and avoiding confrontation. In May 2018, the Veteran’s PTSD was again noted to be stable, with ongoing outpatient treatment, and he was cleared to return to work by a VA vocational rehabilitation specialist. That same month, the Veteran submitted an affidavit included with a TDIU application, which reported ongoing PTSD symptoms including irritability, social isolation, sleep impairment with nightmares, and impaired memory. In June 2018, the Veteran was contacted about starting an additional group therapy class and selected one with a tentative start date two months later. The Veteran denied needing any psychiatric services prior to that time. Upon mental status examination that same month, he again appeared alert and oriented, with appropriate grooming and hygiene, and normal speech, motor activity, thought processes and content, and good judgment and insight. He denied suicidal or homicidal ideation. Notably, the Veteran discussed some recent criminal charges, including a DWI and related probation violations, and stated that he was unaware they existed until he underwent a background check for employment. The following month, in July 2018, he was noted to be employed in logistics. Most recently, upon VA examination in June 2018, the Veteran reported that he lived alone and was unemployed, with past temporary work over the prior year. The examiner documented psychiatric symptoms including depressed mood; anxiety with panic attacks approximately weekly; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; speech intermittently illogical, obscure, or irrelevant; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; 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; inability to establish and maintain effective relationships; obsessional rituals, which interfere with routine activities; impaired impulse control, such as unprovoked irritability with periods of violence; grossly inappropriate behavior; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. When asked which of the following best summarizes the Veteran’s level of occupational and social impairment with regard to all mental diagnoses, the examiner checked “total occupational and social impairment.” While the examiner checked “total occupational and social impairment,” the Board does not find that such establishes entitlement to a 100 percent rating for several reasons. One, as stated above, the adjudicator decides the proper rating. Two, when the examiner is asked the question of which description best summarizes the Veteran’s level of occupational and social impairment, he or she is provided with only the cursory description of “total occupational and social impairment” without the symptoms that are indicative of such level of severity. Three, when checking all the symptoms that applied to the Veteran’s psychiatric diagnosis, the examiner checked two of the seven criteria that fall under the 100 percent rating. The examiner did not find that the Veteran had memory loss for names of close relatives, own occupation, or own name; gross impairment in thought processes or communication; persistent delusions or hallucinations; persistent danger of hurting self or others, or disorientation to time or place. The examiner checked yes to grossly inappropriate behavior and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. It is unclear upon what facts the examiner checked yes to those two symptoms, as a review of the evidence during this part of the appeal does not show these symptoms, to include the Veteran’s own description of his symptoms. The Board finds that the examiner’s ultimate conclusion of total occupational and social impairment is of limited probative value, as it is inconsistent with the clinical findings described in the June 2018 VA PTSD examination and with the evidence of record during the rating period from February 27, 2017, including VA treatment records, which document that the Veteran’s PTSD was stable. Additionally, upon mental status examination, the Veteran appeared alert and oriented, impaired memory, yet the examiner concluded he was capable of managing his own financial affairs and that he did not appear to pose a threat of danger or injury to himself or others. While the examiner stated that the Veteran displayed functional problems, including limits in his ability to recall and carry out detailed instructions; complete a normal workday and workweek without interruptions from psychologically based symptoms; maintain concentration and attention for extended periods; work in coordination with or proximity to others without being distracted by them; respond appropriately to criticism from supervisors; perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; make detailed work-related decisions; respond appropriately to supervision, coworkers and work social situations; and perform job activities at a consistent pace, the Board is mindful that the additional evidence of record suggests that at least some of this impairment resulted from the Veteran’s nonservice-connected alcohol use disorder, as when he was previously sober, he was able to complete two college degrees in social work, despite some reported difficulty. Moreover, while the Veteran denied having friends, he reported attendance at the gym, regularly attending individual therapy with a counselor and group therapy classes, and maintained a good, albeit distant, relationship with one of his daughters and her mother. In sum, the Board finds that the evidence of record from February 27, 2017, including the February 2017 and June 2018 VA examination reports, ongoing VA treatment records, and the Veteran’s own lay reports regarding his PTSD symptoms, is most consistent with the Veteran’s assigned 70 percent disability rating for PTSD with resulting occupational and social impairment with deficiencies in most areas. Given the above, the Board finds that for the period from February 27, 2017, the preponderance of evidence weighs against an increased disability rating in excess of 70 percent for PTSD, as the Veteran’s PTSD symptomatology does not more closely approximate total occupational and social impairment. As the preponderance of the evidence is against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. 4. Entitlement to a TDIU rating. A TDIU rating may be granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. There are minimum disability rating percentages that must be shown for the service-connected disabilities, alone or in combination, to even qualify for consideration for a TDIU award under the schedular criteria. Indeed, if there is only one such disability, it must be rated at 60 percent or more; if instead there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. In determining whether a veteran is unemployable for VA purposes, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. The central inquiry in determining whether a Veteran is entitled to a TDIU rating is whether service-connected disabilities alone are of sufficient severity to produce unemployability. The sole fact that a Veteran is unemployed or has difficulty obtaining employment is not enough; a high disability rating itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. The ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; rather, it is a determination for the adjudicator. The Veteran is currently service connected for PTSD (rated as 30 percent disabling from February 9, 1998, 50 percent disabling from October 17, 2012, and as 70 percent disabling from February 27, 2017), chronic obstructive pulmonary disease (COPD)(rated as 10 percent disabling from October 4, 2000 and as 30 percent disabling from March 29, 2018), fungal infection (rated as 10 percent disabling from December 21, 1991), left knee strain with instability (rated as 10 percent disabling from December 21, 1991) left knee strain with limitation of motion (rated as 10 percent disabling from March 29, 2018), and a left knee scar (rated as noncompensable from March 29, 2018). Based upon the above, the Veteran’s combined disability rating of 20 percent from December 21, 1991, 40 percent from February 9, 1998, 50 percent from October 4, 2000, 60 percent from October 17, 2012, 80 percent from February 27, 2017, and 90 percent from March 29, 2018 meets the schedular criteria for a TDIU rating from February 27, 2017, but no sooner; although the Board is mindful that the failure to meet the schedular percentage requirements prior to that time does not preclude the availability of a TDIU rating on an extraschedular basis. In any event, following a review of the evidence of record, and as discussed below, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to a TDIU rating for the entire period on appeal. In his initial September 2009 TDIU application, the Veteran reported that he was unable to work due to his service-connected PTSD and left knee disabilities; he stated that these disabilities affected his full-time employment in May 1993, that he last worked full-time in December 2003, and that he became too disabled to work in January 2009. The Veteran further reported an educational history including four years of high school plus training in the U.S. Army. Employment information received from a previous employer, PeopleLink, shows the Veteran worked as a general laborer from October 2008 to January 2009, when he was terminated for low assignment completion. An August 2010 decision letter from the Social Security Administration (SSA) documents that the Veteran’s claim for SSA disability benefits was denied. In particular, the SSA decision noted that the Veteran had the residual functional capacity to perform sedentary work, including lifting 20 pounds occasionally and 10 pounds frequently; standing and/or walking for 2 hours out of an 8 hour work day; sitting for up to 6 hours out of an 8 hour work day with the need to alternate sitting and standing every 30 to 60 minutes at a time while remaining at the work station; and additional limitation to simple, unskilled work requiring no contact with the general public and occasional contact with coworkers and supervisors. In the SSA decision, the Administrative Law Judge noted that a vocational expert had testified that considering the Veteran’s disabilities, he would be able to perform the requirements of representative occupations, each of which fell under a sedentary, unskilled position, such as a printed circuit board assembler, with approximately 1,820 jobs in the state of Missouri and 66,500 jobs in the national economy; a wire tapper, with approximately 1,025 jobs in the state of Missouri and 41,625 jobs in the national economy; a production checker, with approximately 430 jobs in the state of Missouri and 16,500 jobs in the national economy; and a document preparer, with approximately 595 jobs in the state of Missouri and 30,000 jobs in the national economy. The Administrative Law Judge noted that the vocational specialist expert’s testimony was consistent with the Dictionary of Occupational Titles and was based upon 22 years of experience. August 2012 VA examinations regarding the Veteran’s service-connected COPD and fungal infection documents that such disabilities did not result in any functional impairment upon his ability to work. Similarly, a more recent June 2018 VA skin examination found no functional impact resulting from the Veteran’s service-connected fungal infection. A September 2013 knee VA examination documents that the Veteran would have difficulty with physically strenuous work due to advanced osteoarthritis and degenerative joint disease; however, the examiner noted that he would be able to engage in light duty and all forms of sedentary work. In this case, the Board finds that sedentary work means work with limited physical activity avoiding substantial walking, carrying, and climbing. A more recent June 2018 VA knees examination also documents functional impairment with certain physical activity and the use of a cane for an assistive device; however, the Board finds that such impairment would not prevent sedentary work as identified by the previous VA examiner. VA treatment records document the Veteran’s participation in vocational rehabilitation services, although these were discontinued in September 2017 due to the Veteran’s incarceration on substance-abuse-related criminal charges. Within a more recent May 2018 TDIU application, the Veteran asserted that his service-connected PTSD, left knee, fungal infection, and COPD prevented his employment. He stated that he last worked full time in January 2003 in shipping and receiving. He noted four years of college, including associates and bachelor’s degrees in social work, which he began in June 2009 and completed in September 2014. Within a concurrent affidavit, the Veteran reported that from 2012 until July 2017, he was unable to hold a part-time position longer than six months. He noted he had performed part-time employment as a cook at Missouri Southern State University from November 2014 until May 2015, but noted that he was often overwhelmed and irritable and called in sick at least 15 days per month due to his PTSD symptoms. He also reported that his PTSD resulted in his termination from a staffing agency in December 2016 after he threatened a co-worker. Most recently, he reported part-time employment at Saint Patrick’s Center as a cleaner/janitor for approximately 15 hours per week on an as-needed basis. The Board has considered the Veteran’s repeated statements that his PTSD has resulted in his unemployability. The Board acknowledges that the objective findings from multiple VA examinations throughout the appeal period document functional impairment due to the Veteran’s PTSD, including occupational impairment. However, other than the inconsistent conclusion of the June 2018 VA examiner, multiple VA examiners have concluded that the Veteran’s PTSD does not preclude sedentary employment, and, as discussed above, the June 2018 examiner’s conclusion of total occupational impairment is of lessened probative value. In the SSA decision, the Administrative Law Judge wrote that vocational expert had found that the Veteran would be capable of performing sedentary unskilled positions, which included a list of the types of positions the Veteran would be capable of doing. The Veteran was able to complete an associate’s and bachelor’s degree in five years, which would establish that he was capable of sedentary employment, as studying, reading, and writing would involve skills that would apply to a sedentary occupation. While the Veteran’s PTSD symptoms impact his occupational capabilities, they do not preclude him from performing sedentary work. The Board finds that the VA examination reports and concurrent VA treatment records document that the Veteran’s PTSD symptoms had their ups and downs but do not establish that it precludes substantially gainful employment. Indeed, the Board is mindful that the high disability ratings already assigned for the Veteran’s PTSD contemplate his level of occupational impairment. Finally, the Veteran has submitted a May 2018 private TDIU vocational assessment that notes the Veteran last worked in a full-time capacity in 2003 and last worked in any capacity in 2017. The vocational expert concluded that it is at least as likely as not that the Veteran has been unable to secure and follow substantially gainful employment since he last maintained full-time employment in 2003, when his symptoms became severe and precluded his ability to continue working at substantially gainful activity levels due to his service-connected PTSD, left knee, and COPD conditions. The Board has considered the May 2018 vocational opinion but ultimately affords it less probative value than the other evidence of record regarding the Veteran’s employability. Notably, the private vocational expert’s opinion was based solely on a telephone interview with the Veteran, while the VA examinations of record discussed in detail above were based upon in-person examinations and objective clinical findings with consideration of the Veteran’s subjective reports. As such, the Board finds that the private vocational expert’s opinion is of lessened probative value than the findings of multiple VA examiners discussed above. Moreover, while the private vocational expert briefly discussed some of the evidence of record as deemed relevant by the expert, he based much of his opinion on the Veteran’s subjective history and failed to acknowledge that the Veteran’s substance abuse is not part of his service-connected PTSD. In sum, while the evidence discussed herein documents some functional impact upon the Veteran’s ability to work based upon his service-connected disabilities, the Board concludes that the preponderance of evidence weighs against the Veteran’s claim for entitlement to a TDIU rating for the entire period on appeal. As such, there is no reasonable doubt to be resolved, and the TDIU claim is denied. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Chad Johnson, Counsel