Citation Nr: 18156108 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 16-48 835 DATE: December 7, 2018 ORDER Entitlement to a rating of 70 percent, but no higher, for a service-connected nervous condition on a schedular basis is granted. Entitlement to a rating in excess of 70 percent for a nervous condition on an extraschedular basis is denied. Entitlement to an effective date of February 24, 2011, but no earlier, for grant of an increased rating for a nervous condition is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. During the appeals period, the Veteran had symptoms of suicidal ideation, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or work-like setting, and impulse control which approximate to symptoms causing occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood; the evidence is insufficient to show total occupational and social impairment. 2. The Veteran’s disability picture is contemplated by the rating schedule and the assigned schedular evaluation is adequate. 3. The Veteran’s February 24, 2011 VA medical record establishes factually ascertainable increased symptoms of his service-connected nervous condition since the initial rating. 4. It is at least equipoise that the Veteran is unable to find and follow substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating of 70 percent, but no higher, for a service-connected nervous condition on a schedular basis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.21, 4.130, Diagnostic Code 9499-9434. 2. The criteria for a rating in excess of 70 percent for a nervous condition on an extraschedular basis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.321(b)(1). 3. The criteria for an effective date of February 24, 2011, but no earlier, for grant of an increased rating for a nervous condition have been met. 38 U.S.C. § 5110 (b)(2) (2012); 38 C.F.R. § 3.400. 4. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 5102, 5103, 5103A 5107(b); 38 C.F.R. §§ 3.340, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the United States Navy from May 1969 to March 1971. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, otherwise the lower rating will apply, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found- a practice known as “staged” ratings. In general, all disabilities, including those arising from a single disease entity, are rated separately, and disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In accordance with 38 C.F.R. §§ 4.1, 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the Veteran’s service-connected disability. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. 1. Entitlement to a rating in excess of 50 percent for a service-connected nervous condition on a schedular basis The Veteran asserts that his nervous condition is such that a rating in excess of 50 percent is warranted. The Veteran is currently rated as 50 percent disabling for a nervous condition under hyphenated Diagnostic Code 9499-9434. The Veteran’s specific psychiatric condition is not listed on the rating schedule, and therefore the RO rated the Veteran’s condition under Diagnostic Code 9499-9434 pursuant to 38 C.F.R. § 4.27, which provides that unlisted disabilities requiring rating by analogy will be coded as the first two numbers of the most closely related body part and “99.” The Veteran’s condition was then rated under the most closely analogous code, Diagnostic Code 9434. 38 C.F.R. § 4.130. Under Diagnostic Code 9434, which is governed by a General Rating Formula for Mental Disorders (General Rating Formula), a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434. A 70 percent 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); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name). Id. 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. 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. 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. Turning to the record of evidence, in a February 2011 VA medical record, the record indicates the Veteran attended a follow-up with the VA psychiatric examiner. The examiner stated that the Veteran was alert, oriented to person, place and time, and was normal in appearance and behavior. The examiner further noted that the Veteran’s speech was normal and flow of thought was logical, sequential and goal oriented. The examiner found the Veteran to have normal memory and concentration. The examiner reported that the Veteran did not have delusions or hallucinations. The examiner also reported that the Veteran had a flat affect, normal judgment and intact insight. The examiner did not note the level of occupational or social impairment these symptoms caused. In a May 2011 VA medical record, the examiner noted that the Veteran continued poor eye contact and focused conversation on his skin condition. The examiner noted that the Veteran was resistant to the possibility of there being any psychological component to his skin problems. The examiner stated that the concept of a psychological reaction worsening a bona fide condition eluded the Veteran. The examiner also noted that while the Veteran was obviously uncomfortable with pruritus, there may be some distortion of the degree of severity of visual lesions pointed out by him. The examiner observed that the Veteran was alert and oriented to person, time, and place. The examiner stated that he was neatly dressed and groomed, and he pleasant and cooperative with the examiner. The examiner went on to state that the Veteran’s motor activity was within normal limits, and his speech was normal in rate rhythm and volume. The examiner stated that the Veteran’s flow of thought was logical, sequential, and goal-oriented, noting that the Veteran ruminates on his skin condition. The examiner stated that the Veteran had normal memory, intact to recall recent and remote memory. The examiner also stated that the Veteran’s concentration was intact, and he had no thoughts or plans to harm or kill himself or others. The examiner noted that the Veteran had normal perceptions with no auditory visual or tactile hallucinations. The examiner went on to note that no delusions were expressed or elicited. The examiner stated that the Veteran’s mood was depressed, angry and anxious, and his affect was flat. The examiner found that the Veteran had normal judgment, but stated that the Veteran’s insight was in partial denial. In a July 2011 statement in support of claim, the Veteran stated that he was nervous all the time and had no patience for anyone or anything. The Veteran stated that he had no friends outside his family and that he hated dealing with his neighbors. The Veteran further reported that he could no longer go swimming because he didn’t want others to see his skin. The Veteran reported that he paces and often thinks about death, to include thoughts of overdose of medication. The Veteran reported that his wife drives because he cannot concentrate and gets angry at other drivers. He further reported getting angry at his wife while she drives. The Veteran noted that his wife helped him apply his medication to his back. The Veteran went on to state that he secludes himself due to his outbursts, and he was embarrassed to go places because of his skin. The Veteran further stated that has not worked since January 2002 and he is depressed that he is not able to work. In a July 2011 buddy statement, the Veteran’s son reported that the Veteran was less friendly and outgoing than previously. He also reported that the Veteran was often exhausted and irritated. The Veteran’s son further reported that the Veteran’s outlook on life had diminished, and noted that the Veteran constantly talks about dying soon. In a separate July 2011 buddy statement, the Veteran’s wife stated that the Veteran no longer had patience with his family members. She also reported that the Veteran is agitated and tired easily. She noted that the Veteran occasionally has crying spells, and does not sleep very long. The Veteran’s wife stated that the Veteran can no longer drive because he gets nervous and angry. She also noted that the Veteran sometimes talked about suicide because he was tired of feeling the way he did and medication did not work. In a July 2011 VA examination, the Veteran reported that he did not enjoy activities anymore, stating that he used to golf and have friends. The Veteran also reported that he no longer drives, and he watches television all day. The examiner stated the Veteran appeared unshaven and casually dressed. The examiner reported that the Veteran was alert and oriented. The examiner observed that the Veteran’s affect was constricted. The examiner further noted unremarkable speech, rate, and tone. The examiner stated that the Veteran’s thought content and progression focused the conversation on his skin condition and provided frequent unsolicited comments regarding his inability to function around others, inability to sleep, etc. The examiner reported that tangentiality, circumstantiality, loose associations, and flight of ideas were unremarkable. The examiner stated that the Veteran denied current suicidal or homicidal ideation. The examiner also stated that the Veteran’s attention was within normal limits, and there was no evidence to suggest difficulty with attention and concentration during the evaluation. The examiner reported that the Veteran was able to maintain focus and resist distractions from environmental factors. The examiner noted that the Veteran’s insight and judgment were good, and his abstract thinking and memory were within normal limits. The examiner also stated that the Veteran was able to manage his financial affairs. The examiner stated that the Veteran reported an inability to sleep due to his skin itching and esophagus problems. The examiner also noted that the Veteran reported an angry mood, irritability, depression and restlessness. The examiner further noted the Veteran’s report of anxiousness. The examiner noted that the Veteran stated that he talked about dying all the time, but recent clinical psychiatry notes indicate that the Veteran denied thoughts or plans to harm or kill self or others. After providing a multi-axial, self-administered, screening measure for detection of malingering, the examiner reported that the Veteran’s score was significantly higher than the recommended cut-off score for identification of malingering. The examiner noted that the Veteran endorsed a high number of bizarre or unusual psychotic symptoms not typically present in actual psychiatric patients, as well as illogical and highly atypical neurological symptoms and symptoms of memory impairment that are inconsistent with patterns of impairment seen in brain dysfunction or injury. The examiner went on to state that the Veteran additionally endorsed a high number of atypical symptoms of depression and anxiety along with items suggesting attempts to feign general cognitive incapacity or intellectual deficits. The examiner stated that the Veteran endorsed a high frequency of symptoms that were atypical in patients with genuine psychiatric or cognitive disorders, raising suspicion of intentional production of false or grossly exaggerated symptoms as motivated by external incentive. The examiner remarked that, when asked to describe symptoms consistent with depression and anxiety, the Veteran spoke in overly general, vague, evasive terms, and he was generally unable to describe his own symptomatology in terms that were unique to him. The examiner further reported that when asked specific questions regarding depression and anxiety, the Veteran endorsed and identified the highest levels of distress. The examiner commented that this made the Veteran’s responses highly questionable and difficult to determine the actual presence and/or intensity of symptoms. The examiner reiterated that psychological testing results were suggestive of significant feigning/ over-reporting of symptomatology, raising the question as to the accuracy of the Veteran’s subjective, self-report, especially in the context of this examination. The examiner did not provide a diagnosis, concluding there was an inability to assess given the evidence of malingering. The examiner stated that the results were not considered to be a valid measure of the Veteran’s current functioning or the relationship between his mental health and his current occupational and social functioning, and thus, no further interpretation of results could be conducted. In a November 2011 VA medical record, the Veteran stated that due to his skin condition, he was unable to concentrate enough to read or do much of anything. He stated that this was a constant distraction in his life. The examiner stated that there were no acute affective symptoms, and that the Veteran denied suicidal and homicidal ideation. The examiner observed that the Veteran was uncomfortable and scratching the entire session. The examiner noted that the Veteran tried to minimize, but was unable. The examiner found that the Veteran had normal memory, intact to recall recent and remote memory. The examiner also stated that the Veteran’s concentration was intact, and he had no thoughts or plans to harm or kill himself or others. The examiner noted that the Veteran had normal perceptions with no auditory, visual, or tactile hallucinations. The examiner went on to note that no delusions were expressed or elicited. The examiner stated that the Veteran’s mood was depressed, angry, and anxious, and his affect was appropriate to mood with normal range. The examiner found that the Veteran had normal judgment, and his insight was intact. In a February 2013 VA medical record, the examiner noted that the Veteran presented cleanly and casually dressed. The examiner stated that the Veteran did not speak, but allowed his wife to speak for him. The examiner noted very poor eye contact. The examiner observed that the Veteran was passive with flat affect. The examiner also noted that the Veteran was guarded. The Veteran’s wife stated that she has been shaving, cutting his hair and dressing him for years. She stated that he isolated himself at home and had no friends. She also reported that they had no social life. She stated that the Veteran stayed in his pajamas almost every day. She also stated that he will grab the wheel when she is driving if someone cuts them off. She stated that the Veteran feels the other person is directly after him personally, describing paranoia. The examiner stated that the Veteran presented as neurovegetative in the office and lifestyle. The Veteran’s wife stated that she was unable to work a job as he needed her 24-hour care. In a September 2015 VA medical record, the Veteran reported to the psychiatrist. The examiner noted that the Veteran’s wife did almost all of the talking for him while he only made a couple of sounds. The examiner observed that the Veteran was aware but essentially refused to speak. The examiner noted that the Veteran did not interject when he was spoken of in the third person. The examiner observed that the Veteran had a normal appearance and was oriented to person and place. The examiner stated that the Veteran’s behavior was withdrawn, motor activity was minimal, and speech was unproductive and mute. The examiner stated that the Veteran had normal perceptions with no auditory, visual or tactile hallucinations, and no delusions were expressed or elicited. On April 7, 2016, the Veteran presented for a scheduled compensation and pension mental health disability evaluation, brought by his wife. The examiner stated that the Veteran was taken back by a nurse for computerized testing. It was at this time that the nurse found the Veteran to be minimally responsive to his own name, responding to questions in a mumbled tone, and was observed to be profusely scratching his entire body. Testing was discontinued. The examiner went on to report that the Veteran was asked to ambulate approximately 25 feet for his mental health evaluation, in which he initially attempted to roll the chair he was sitting in, but then when he attempted to walk, his gait was notably unstable. The examiner stated that, upon evaluation, the Veteran continued to scratch his entire body, stared at the floor, rocked in his chair, and was minimally responsive to questioning. The examiner stated that it should be noted that the Veteran did respond appropriately to questions, albeit in mumbled and barely audible tones that were perseverative at times. The examiner reported he also displayed inappropriate laughing, particularly when discussing current thoughts of suicide. When the Veteran was asked directly regarding thoughts of suicide, the Veteran denied developing a specific plan, but he believed the voice would somehow kill him. The Veteran reported experiencing auditory hallucinations for a long time and constantly at night. Additionally, he reported experiencing visual hallucinations as well. However, the examiner noted that this report was somewhat unclear as the Veteran did not report a history of auditory/visual hallucinations to his treating psychiatrist in a follow-up visit that occurred just the day before the evaluation. As a result of the reported nature of ongoing auditory and visual hallucinations and at minimum passive suicidal thoughts, the examiner informed the Veteran and his wife that further immediate evaluation at the emergency room was necessary to ensure the safety of the Veteran. The examiner noted that Veteran lost control of his bladder while sitting in the examiner’s office in the wheelchair. The examiner also noted that, as the Veteran was unwilling to be transported voluntarily, an ambulance was called to transport the Veteran. An April 14, 2016 record indicates that the Veteran was diagnosed with psychosis, not otherwise specified, possibly secondary to major depressive disorders, severe, or possibly secondary to dementia, severe major depressive disorder, and generalized anxiety disorder. The examiner noted that in the initial paperwork, the Veteran reported that he did not want to live with the pain he experienced every day, and reported hearing voices that wanted to attack him with the metal. The examiner reported that the Veteran did not seem to remember the report that he stated in the paperwork, and reported that he had not heard any voices and has not for a long time. The examiner reported that the Veteran’s wife stated that he generally did not have poor memory; however, when he became over-stressed, he could not think very well and became dehydrated easily. The Veteran’s wife further reported that the Veteran suffered from chronic pain, was paranoid at home, hears things at night, often checks the security cameras, and had a fear of leaving the house. The examiner noted that the Veteran’s medical record was not available at the time of the report. The examiner observed that the Veteran was alert with some psychomotor agitation. The examiner reported that the Veteran was not cooperative with the examiner, either through inability or unwillingness, inability seeming more likely. The examiner noted that the Veteran was disheveled, and did not make eye contact throughout the course of the interview. The examiner stated that the Veteran was unresponsive roughly 60 to 70 percent of the questions being asked. The examiner reported that the Veteran’s mood was not obtainable, but his affect was congruent with being anxious and possibly afraid. The examiner stated that the Veteran may have been responding to internal stimuli, which may account for the increased latency of response or lack of response to many of the questions, and minimal response to questions. The examiner stated that the Veteran was not expressing delusional ideas. The examiner observed that the Veteran did not appear to be cognitively intact. The examiner noted poor insight, judgment, and impulse control. The examiner noted that the Veteran did not express suicidal ideation; however, the Veteran was minimally responsive. An April 15, 2016 progress note states that the Veteran was observed interacting with other patients, making eye contact during conversation, and walking with no distress. The examiner stated that the Veteran denied suicidal or homicidal ideation. The examiner further noted that the Veteran denied auditory or visual hallucinations. The examiner observed that the Veteran appeared cognitively intact. In an April 21, 2016 VA examination, the Veteran denied contact with his family, stating that they did not like him. He described his daily activity as sitting at home and watching his camera. The Veteran noted that he slept during the day. The Veteran reported that his wife quit her job and takes care of him. He stated that he has yelled at his wife, but denied hitting anyone. The Veteran stated that he seldom went out to eat, and that he has a fear of insects. The Veteran reported that he has some relationship with his granddaughter, but he knows she is scared of him. He further reported that he had two boys, of whom he is very proud. The examiner observed that the Veteran was adequately groomed and dressed in clean appropriate attire. The examiner reported that the Veteran was cooperative with the examiner, not distractible, and maintained appropriate eye contact throughout the interview. The examiner noted that the Veteran's speech was spontaneous, easily understood, and of average rate and volume. The examiner went on to note that the Veteran’s mood was labile, angry, oppositional, and tearful, and his affect was labile with mood based on demeanor and conversational content. The examiner stated that the Veteran was alert and oriented. The examiner also stated that the Veteran’s immediate, recent, and remote memory was intact, and he demonstrated no deficits in concentration. The examiner reported that the Veteran was coherent, logical, and goal-directed. The examiner noted that the Veteran did not report auditory or visual hallucinations, delusions or illusions. The examiner stated that the Veteran did not appear to be responding to internal stimuli. The examiner noted that the Veteran was not having thought blocking, and his speech was not circumstantial or tangential. The examiner stated that the Veteran had poor insight and judgment. The examiner reported that the Veteran denied any significant problems with activities of daily living. The examiner noted that the Veteran reported frequency of symptoms as “all the time.” Similarly, the examiner noted that the Veteran reported duration of symptoms of depression, anxiety, nervousness, restlessness, trouble making decisions, irritability and easily fatigued as “all the time.” The examiner stated that the severity of symptoms was impossible to determine due to the Veteran’s over-reporting of symptoms without resorting to mere speculation. The examiner remarked that the Veteran’s responses resulted in an invalid profile. The examiner explained that the degree of psychopathology that he endorsed is unusual even in a clinical population. The examiner further stated that, while it may be that the results represent an expression of distress and/or a “cry for help,” it is quite likely that there was some intentional exaggeration of the current symptom picture, possibly for secondary gain. The examiner stated that the Veteran’s ability to understand and follow instructions is considered not profoundly impaired. The examiner noted that the Veteran’s ability to retain instructions as well as sustain concentration to perform simple tasks is considered not impaired. The examiner further noted that the Veteran’s ability to sustain concentration to task persistence and pace is considered moderately impaired. The examiner stated that the Veteran’s ability to respond appropriately to coworkers, supervisors, or the general public and his ability to respond appropriately to changes in the work setting are considered moderately impaired. The examiner concluded that the Veteran’s mental condition does not preclude occupational functioning in a sedentary, structured, solitary work environment that accommodates physical limitations. In an April 28, 2016 addendum, the examiner confirmed symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, near continuous panic, impairment of short and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks, difficulty in establishing and maintaining effective work and social relationships, disturbances of motivation and mood, difficulty adapting to stressful circumstances, including work or work-like setting, suicidal ideation and impaired impulse control. The examiner summarized the Veteran’s occupational and social impairment as occupational and social impairment with reduced reliability and productivity. After review of the record, the Board finds that a 70 percent rating throughout the appeals period is warranted. During the appeals period, the Veteran had symptoms of suicidal ideation, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or work-like setting, and impulse control. While the April 2016 VA examination notes social and occupational impairment with reduced reliability and productivity, these symptoms more closely approximate to those causing occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking, and mood. Therefore, the Veteran’s disability more closely approximates to a 70 percent rating. The evidence of record does not show that the Veteran’s symptoms produce total occupational and social impairment as to warrant a 100 percent rating. The record does not establish that the Veteran has gross impairment in thought processes or communication, grossly inappropriate behavior, or disorientation to time or place. The Board notes the Veteran’s April 2016 hospitalization; however, the record indicates that this was an isolated incident in which the Veteran recovered within five days. The Board also notes that the record indicates that the Veteran’s wife stays home to help take care of the Veteran; however, the April 2016 VA examination indicates that the Veteran does not have problems with performing daily activities of living. While the Veteran has endorsed passive suicidal ideation and that he gets angry at his wife and when he is in the car, the record does not show that the Veteran is a persistent danger to himself or others. Furthermore, while the record indicates memory loss, it is not so severe such that the Veteran does not remember names of close relatives, own occupation, or own name. Finally, the Board notes that, although there are reports of hallucinations, the record is inconsistent on report of these symptoms. Moreover, the Board notes that both the November 2011 and April 2016 examiners found substantial evidence of malingering, particularly with the most severe symptoms. For these reasons, the Board finds that a 100 percent rating is not warranted. In reaching this decision, the Board has considered the Veteran’s lay statements and the supporting statements submitted on his behalf. The Board notes that the Veteran is competent to report observations with regard to the severity of his symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, as noted above, the medical evidence of record establishes that the Veteran’s self-report of symptoms indicate malingering. The Board has found corroborating lay statements to be credible and consistent with the rating now assigned. To the extent the Veteran argues his symptomatology is more severe, the Veteran’s statements must be weighed against the other evidence of the record. Here, the specific examination findings of trained health care professionals and documented medical treatment records are of greater probative weight than the more general lay assertions that a rating higher than 70 percent is warranted. 2. Entitlement to a rating in excess of 70 percent for a nervous condition, on an extraschedular basis The Board has also considered whether the Veteran’s nervous condition presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (“[R]ating schedule will apply unless there are ‘exceptional or unusual’ factors which render application of the schedule impractical.”). Here, the rating criteria reasonably describe the Veteran’s disability level and symptomatology, and provide for a higher rating for additional or more severe symptomatology than is shown by the evidence. The Veteran’s rating for his service-connected nervous condition contemplates his symptoms of depression, anxiety, irritability, impulse control, and suicidal ideation. Although the Veteran experienced depression, anxiety, and suicidal ideation, these symptoms were not found to warrant the next higher rating of 100 percent. Indeed, while the Veteran has denied most relationships, the evidence indicates that he does maintain relationships with his wife and his sons. The Board acknowledges the Veteran’s representative’s contention that consideration should be given to the Veteran’s loss of bladder control prior to his April 2016 hospitalization. The Board notes that the Veteran’s hospitalization was an isolated incident. As such, the entirety of the Veteran’s subjective complaints including his symptoms, objective findings, and occupational and social impairment are addressed in the higher 70 percent rating assigned in this decision. Thus, the Veteran’s disability picture is contemplated by the rating schedule and the assigned schedular evaluation is adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. Effective Date The general rule regarding effective dates is that the effective date of an evaluation and award of compensation based on an original claim, a claim re-opened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such an informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year after the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a). The effective date of a grant of an increased rating is the earliest date as of which it is factually ascertainable that an increase in disability has occurred, if the claim is received within a year from that date. Otherwise, the effective date is the later of the date of increase in disability or the date of receipt of the claim. 38 U.S.C. § 5110 (b)(2) (2012); 38 C.F.R. § 3.400 (o)(2) (2017); Harper v. Brown, 10 Vet. App. 125 (1997). However, 38 U.S.C. § 5110 (b)(2) and 38 C.F.R. § 3.400 (o)(2) are applicable only where the increase precedes the claim, provided also that the claim is received within one year after the increase. In those cases, the Board must determine under the evidence of record the earliest date that the increased rating was ascertainable. Hazan v. Gober, 10 Vet. App. 511 (1997); Harper v. Brown, 10 Vet. App. 125 (1997); VAOPGCPREC 12-98 (1998), 63 Fed. Reg. 56705 (1998). An effective date earlier than May 31, 2011, for grant of an increased rating for a nervous condition The Veteran contends that the proper effective date for grant of a noninitial increased rating for service connected nervous condition is February 24, 2011. Turning to the evidence of record, on May 31, 2011, the Veteran applied for a rating in excess of 10 percent for his nervous condition. In an April 2012 rating decision, the RO granted a 30 percent rating for a nervous condition, effective February 24, 2011. In an August 2016 rating decision, the RO increased the Veteran’s nervous condition rating to 50 percent. It found that the assignment of the February 24, 2011 date was a clear and unmistakable error and reassigned the effective date to May 31, 2011, the date of filing. The RO noted that the Veteran discussed an increase based on previous Global Assessment of Function (GAF) Scale Scores as evidence of an increase in symptoms. The RO noted that the GAF is reviewed when present, but this scale is not binding. However, it is taken into consideration in determining the severity of disability for evaluation purposes. In January 2017 correspondence, the Veteran, through his representative, asserted that February 24, 2011 is the date the Veteran’s medical records document worsening symptoms. The representative references the Veteran’s son’s June 2011 statement that indicated that his symptoms had been deteriorating for quite some time. Regarding the February 2011 VA medical record referenced by the Veteran’s January 2017 representative correspondence, the record indicates the Veteran attended a follow-up with the VA psychiatric examiner. The examiner stated that the Veteran was alert, oriented to person, place and time, and was normal in appearance and behavior. The examiner further noted that the Veteran’s speech was normal and flow of thought was logical, sequential and goal oriented. The examiner found the Veteran to have normal memory and concentration. The examiner reported that the Veteran did not have delusions or hallucinations. The examiner also reported that the Veteran had a flat affect, normal judgment and intact insight. The examiner did not note the level of occupational or social impairment these symptoms caused. After review of the evidence, the Board finds that an earlier effective date than May 31, 2011, for a noninitial increased disability rating for a service-connected nervous condition is warranted. The Veteran’s February 24, 2011 VA medical record establishes factually ascertainable increased symptoms such as flattened affect. Therefore, February 24, 2011 is the earliest possible effective date, as it is the date the increase in symptomatology was factually ascertainable within a year of the filing of the claim. TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340(a)(1), 4.15. 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; 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. For the Veteran to prevail on a claim for a TDIU, the sole fact that the Veteran is unemployed or has difficulty obtaining employment is not enough. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). In determining whether the Veteran is entitled to a TDIU, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but not to his or her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). Substantially gainful employment means, essentially, that the work provides income above the poverty level established by the United States Department of Commerce, without benefit of protected family employment or a sheltered workshop. 38 C.F.R. § 4.16(a). Entitlement to a TDIU The Veteran contends that his service-connected disabilities render him unable to gain and maintain substantially gainful employment. Throughout the appeals period, the Veteran is service-connected for the following: a nervous condition at 70 percent disabling, skin acne at 30 percent disabling, tinnitus at 10 percent, gastroesophageal disorder at 10 percent, and noncompensable bilateral hearing loss. The Veteran has a combined rating of 80 percent disabling, and therefore meets the schedular criteria for a TDIU. Turning to the record of evidence, the July 2011 VA examination for nervous condition indicates that the Veteran has not worked for ten years. The Veteran reported that his last employment was as a supervisor in manufacturing for two years. The record further states that, prior to his last employer, the Veteran worked for IBM for fifteen years. In a July 2011 statement in support of that claim, the Veteran stated that he was depressed that he was unable to work. The Veteran also stated that he did not go out often due to his skin condition. The Veteran’s wife submitted a statement July 2011 buddy statement which indicated that the Veteran was no longer able to drive. The Veteran’s wife also confirmed that the Veteran was unable to sleep at night due both to his scratching and his anxiety. In the July 2011 VA examination, the examiner reported that occupational and social impairment was not able to be assessed based on the examination due to suspected malingering of symptoms. In a November 2011 VA medical report, the Veteran stated that his skin condition was a constant distraction in his life. The examiner observed that the Veteran was uncomfortable and scratching the entire session. The examiner noted that the Veteran tried to minimize, but could not. In the April 2016 VA examination, the examiner found the Veteran’s ability to understand and follow instructions is considered not profoundly impaired. The examiner noted that the Veteran’s ability to retain instructions as well as sustain concentration to perform simple tasks is considered not impaired. The examiner further noted that the Veteran’s ability to sustain concentration to task persistence and pace is considered moderately impaired. The examiner stated that the Veteran’s ability to respond appropriately to coworkers, supervisors, or the general public and his ability to respond appropriately to changes in the work setting are considered moderately impaired. The examiner concluded that the Veteran’s mental condition does not preclude occupational functioning in a sedentary, structured, solitary work environment that accommodates physical limitations. Nevertheless, the examiner endorsed symptoms of difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or work-like setting. After review of the evidence, the Board finds that it is at least equipoise that the Veteran is unable to find and follow substantially gainful employment due to his service-connected disabilities. While the April 2016 VA opinion states that the Veteran’s mental condition would not prohibit his ability to find gainful employment, the Board notes that the Veteran’s psychiatric condition, in aggregate with his skin condition, has prevented the Veteran from gaining sleep at hours conducive to a work environment. Furthermore, as the same examiner endorsed that the Veteran has symptoms of difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or work-like setting, and giving the Veteran the benefit of the doubt, it is at least equipoise that the Veteran is unable to secure substantially gainful employment. Therefore, a TDIU is granted. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Ford, Associate Counsel