Citation Nr: 18158215 Decision Date: 12/18/18 Archive Date: 12/14/18 DOCKET NO. 12-24 916 DATE: December 18, 2018 ORDER The claim of entitlement to an initial rating greater than 10 percent for posttraumatic stress disorder (PTSD), prior to April 8, 2015, is denied. The claim of entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, prior to August 14, 2013, is denied. FINDINGS OF FACT 1. From the September 2, 2009 effective date of the award of service connection for PTSD, to April 8, 2015, the Veteran’s service-connected PTSD symptoms included difficulty sleeping, nightmares and flashbacks, avoidance of crowds, and anxiety. Collectively, these symptoms are of the type and extent, frequency and/or severity (as appropriate), to suggest no more than occupational and social impairment due to mild or transient symptoms, which decrease work efficiency and ability to perform occupational tasks only during episodes of significant stress, or symptoms controlled by continuous medication. 2. The Veteran filed a claim for a TDIU on October 14, 2009, which the Regional Office (RO) denied in August 2010. 3. Service connection has been established for nephropathy with hypertension associated with DM (rated at 20 percent from July 7, 2008; at 60 percent from October 31, 2011; and at 80 percent from May 22, 2013); PTSD (rated at 10 percent from September 2, 2009, and at 70 percent from April 8, 2015); DM with cataracts, retinopathy, and erectile dysfunction (rated at 20 percent from May 8, 2001), right shoulder disability (rated at 20 percent from August 11, 2008); right lower extremity neuropathy, sciatic nerve (rated at 10 percent from July 7, 2008/ and 20 percent from August 14, 2013); right upper extremity neuropathy associated with DM (rated at 20 percent from August 14, 2013); left upper extremity neuropathy associated with DM (rated at 20 percent from August 14, 2013); left lower extremity neuropathy (rated at 10 percent from July 7, 2008); right lower extremity neuropathy, femoral nerve, associated with DM (rated at 10 percent from August 14, 2013); left lower extremity neuropathy, femoral nerve, associated with DM (rated at 10 percent from August 14, 2013); hypertension associated with DM (rated as 10 percent from July 7, 2008); bilateral hearing loss (rated as noncompensable from December 9, 1997; and at 10 percent from April 30, 2008; 20 percent from August 20, 2009; and 10 percent from March 1, 2012); right shoulder scar (rated as noncompensable from August 11, 2008); and scar above the right eye (rated as noncompensable from April 13, 2010). The combined disability ratings are as follows: noncompensable from December 9, 1997; 30 percent from May 8, 2001; 40 percent from April 30, 2008; 60 percent from July 7, 2008; 80 percent from September 2, 2009; 90 percent from October 31, 2011; 80 percent from March 1, 2012; 90 percent from May 22, 2013; and 100 percent from August 14, 2013. 4. Although the Veteran met the percentage requirements for the award of a schedular TDIU as of the filing of his October 14, 2009 claim, the weight of the competent, probative evidence indicates that, prior to August 14, 2013, the Veteran’s service-connected disabilities did not prevent him from obtaining or retaining substantially gainful employment consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. The criteria for an initial rating greater than 10 percent for PTSD, prior to April 8, 2015, are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a TDIU, prior to August 14, 2013, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§3.102, 3.340, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from February 1968 to February 1971. This appeal to the Board of Veterans’ Appeals (Board) arose from RO rating decisions dated August 23, 2010, August 14, 2012, and August 17, 2012. In the August 23, 2010 rating decision, the RO, inter alia, denied a TDIU. In November 2010, the Veteran filed a notice of disagreement (NOD) with this denial. A statement of the case (SOC) was issued in August 2012, and the Veteran filed a substantive appeal via a (VA Form 9, Appeal to the Board of Veterans’ Appeals) in September 2012. In the August 14, 2012, rating decision, the RO, inter alia, granted service connection for a right shoulder disability, effective August 11, 2008. In the August 17, 2012 rating decision, the RO, inter alia, granted service connection for PTSD and assigned a 10 percent disability rating from September 2, 2009. In September 2012, the Veteran filed an NOD with the initial rating assigned for PTSD; and, in November 2012, the Veteran filed an NOD with the effective date for the right shoulder disability award. The RO issued a statement of the case (SOC) addressing both claims in April 2013, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans’ Appeals) in May 2013. In May 2016, the Veteran and his wife testified during a Board hearing before the undersigned Veterans Law Judge (VLJ) at the Las Vegas satellite office of the Reno RO; a transcript of that hearing is of record. In September 2016, the Board denied an effective date earlier than August 11, 2008 for the award of service connection for a right shoulder disability, ratings in excess of 10 percent prior to April 8, 2015 and 70 percent thereafter for PTSD, and a TDIU prior to August 14, 2013. The Veteran appealed the Board’s September 2016 decision to the United States Court of Appeals for Veterans Claims (Court). In March 2018, the Court issued a Memorandum Decision, vacating those portions of the September 2016 Board decision that denied a rating greater than 10 percent for PTSD prior to April 8, 2015, and a TDIU prior to August 14, 2013, and remanding these claims to the Board for further proceedings consistent with the Memorandum Decision. I. Evaluation of PTSD prior to April 8, 2015 Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this case, as the AOJ already assigned staged ratings for the Veteran’s PTSD, the Board must consider the propriety of the ratings assigned, as well as whether any further staged rating is appropriate. The ratings for the Veteran’s psychiatric disability have been assigned under Diagnostic Code 9411. However, psychiatric disabilities other than eating disorders are actually rated pursuant to the criteria of a General Rating Formula. See 38 C.F.R. § 4.130. Under the General Rating Formula, a 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms, which decrease work efficiency and ability to perform occupational tasks only during episodes of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is assigned for 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 rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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 inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit has explained, evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating” under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas”-i.e., “the regulation ... requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.’” Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. When evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.” 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). Historically, psychiatric examinations frequently included assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health illness.” There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). [Parenthetically, the Board notes that the, revised DSM-5, which among other things, eliminates GAF scores, applies to cases certified to the Board after August 4, 2014. See 79 Fed. Reg. 45,093 (Aug. 4, 2014))]. VA treatment records dated in August 2009 reflect that the Veteran was hypervigilant, as evidenced by him “taking off” after hearing the sound of a car backing up. His mood and affect were euthymic; his thinking was linear; his insight and judgment were intact; and he did not exhibit psychotic, suicidal, or homicidal tendencies. The attending physician noted that he presented with mood swings, anger management problems, chronic pain, nightmares, and opioid medication use for pain symptoms. September 2009 records note that the Veteran had five prior marriages and was married to his current wife for 12 years. He had one adult son with whom he spoke twice a week, and a close relationship with his siblings. He went to church regularly and took road trips in the country. The social worker remarked that he appeared to have a significant decline in social functioning associated with his psychosis and mood instability, and while he was aware that his functioning was poor, he seemed sure that his delusions were real. He was assigned a GAF score of 45. In November 2009, the attending psychiatrist assigned the Veteran a GAF score of 35 and diagnosed him with schizoaffective disorder, bipolar type; alcohol dependence, early full remission; cocaine dependence, early partial remission; opioid dependence, sustained full remission; polysubstance dependence, early full remission; and PTSD. The psychiatrist observed that the Veteran suffered from severe PTSD, delusions, and was very paranoid. He was depressed and exhibited symptoms of sad mood, decreased concentration, decreased energy, decreased pleasure, sleep disturbance, isolation, guilt, crying spells, appetite disturbance, and feelings of hopelessness. The Veteran gave a long history of substance abuse, paranoia, and symptoms of PTSD. He reported avoidance of trauma-related stimuli, flashbacks of intrusive traumatic memories, exaggerated startle response, isolation from loved ones, intense guilt, nightmares of trauma, emotional numbing, anger control problems, and a shortened sense of future. In March 2010, the Veteran's wife stated that he would thrash in his sleep and sometimes wake up “in a fierce fright like he [was] fighting for his life like trying to escape from something or like someone [was] chasing him.” She noted that he was in emotional pain and lived in the past, and that he would have flashbacks and start talking and acting as if he were still in Vietnam. An August 2010 VA examination report revealed that the Veteran had been married five times and that he had been in his current marriage for approximately 15 years. The examiner noted that the Veteran had reported “numerous odd events” in his life that were “implausible and [had] no evidence to support them,” which appeared “to be part of delusional symptoms possibly aggravated by his substance abuse.” The Veteran reported that he was forgetful, depressed, unhappy, uninterested in things that used to be pleasurable, and that he did not “want to deal with people.” He experienced flashbacks that were unrelated to his confirmed stressor, had middle insomnia and woke up six to eight times per night, and heard voices telling him that he had killed people and that God would get him. He stated that he had thought of suicide numerous times in the past but that he was “too old to do that now.” He denied any sort of homicidal ideations, although there was a significant history of aggression mainly in terms of domestic violence. He exhibited antisocial traits, and stated that while he did not have many social contacts, he went to church regularly and saw his brother and son frequently. The examiner noted that the Veteran presented as a very odd and intense individual who was overly dramatic and hysterical at times, and gave extreme description of his problems often using hyperboles. He was very focused on his entitlement to benefits and how everyone had treated him badly in his life. He was casually dressed and poorly groomed with a strong smell of body odor. He was verbal during the interview, but the examiner found that a rapport was difficult to establish. His social skills were poor, his thought process was illogical at times and altered by delusions, and he tended to ramble. He exhibited concentration and memory problems, and showed deficits in long-term memory mainly due to confabulation, possibly related to substance abuse. The examiner noted that the Veteran had a significant history of head injury when a bullet grazed his head sometime in the 1980s. The examiner remarked that the onset of mental health symptoms, aside from the substance abuse, appeared to have emerged after having been shot in the head. The Veteran described profound social and occupational impairment, but he was not considered an accurate historian, and there were clear indications of symptom exaggeration, which brought the Veteran’s credibility further into question. The examiner opined that the Veteran’s profound social and occupational impairments could be fully attributed to his substance abuse, personality disorder, possible sequela from the head injury in the early 1980s, and what appeared to be substance-induced psychosis, none of which were service-connected. He diagnosed the Veteran with polysubstance dependence, unknown status; depressive disorder not otherwise specified (NOS), but most likely related to the negative fallout from antisocial behaviors and substance abuse; psychosis NOS; and personality disorder NOS with paranoid, antisocial, and schizoid traits. The examiner concluded that the Veteran was “clearly quite disturbed and presented with total impairment though the origin of this did not appear to be related to his military service.” In April 2012, a VA staff physician noted that the Veteran had a history of psychosis, and that he stated that he continued to hear intermittent voices of his deceased brother and mother talking to him. He appeared to externalize and was very suspicious of others. Nevertheless, he denied symptoms consistent with mania; any current violent ideation, intent, or plan; and denied any history of violence or of being arrested in the past. However, the physician noted that prior examinations revealed that the Veteran had a history of violence, specifically domestic violence toward his previous and current wives, as well as a history of incarceration during his youth. The Veteran reported that he had been married for 15 years and attended church 3 times per week. The Veteran related that he was very intelligent with a college degree and did not have any cognitive deficits that would create problems in managing his finances. However, the physician noted that when discussing his PTSD, the Veteran stated that he was having severe memory problems and forgetfulness to the point where he could not remember where he had parked his car, people'’ names, and important details from the past. The physician stated that he could not reconcile the inconsistency in the Veteran’s self-reports. Regarding his PTSD-type symptoms, the Veteran stated that he continued to have severe nightmares; intrusive recurring memories; anxiety and hyperarousal, to include mistrust of others; anger; and some avoidance behaviors related to his military experiences. However, his wife reported he was “constantly talking about Vietnam, about all the things that happened ... all day and all night.” The physician noted that this appeared inconsistent with trigger-related avoidance behavior. The Veteran also stated that he had depression with hypersomnia to the point that he regularly slept 12 to 14 hours per day. He reported anhedonia, low energy, poor concentration and memory, and increased appetite. He also remarked that he felt some hopelessness in the past with some suicidal ideation, but he had never wanted to follow through and was adamant that he never would. The physician noted that the Veteran was dressed and groomed appropriately; he did not exhibit any abnormal movements; and his speech was normal, although he often talked over the physician, who remarked that overall the Veteran was defensive throughout the interview. His mood was depressed, his affect was angry and restricted, he was alert and oriented, his judgment and insight were poor, and he had no suicidal or homicidal ideations. He did not exhibit current auditory or visual hallucinations, although he reported he did have auditory hallucinations at times. He appeared paranoid, and the physician found that it might not be at the level of a delusion, but rather a personality trait with significant externalizing. He diagnosed the Veteran with depression NOS; anxiety disorder NOS; psychosis NOS; and intermittent polysubstance dependence (cocaine, opiate, alcohol, cannabis), reportedly in full sustained remission. A May 2012 report of VA examination revealed diagnoses of PTSD; depressive disorder, NOS; polysubstance dependence, in remission; and personality disorder, NOS, with paranoid, antisocial, and schizoid traits. The examiner found that the Veteran’s substance use had an onset prior to his mental health condition and had independently caused impairment in psychosocial functioning. The substance abuse had aggravated his psychiatric symptoms because it disrupted his REM sleep, disinhibited his temper outbursts, caused cognitive decline, decreased motivation, and increased anhedonia. The examiner noted that there had been severe negative sequela of substance abuse that contributed to the Veteran’s depression and psychosocial impairment. Additionally, the Veteran’s sleep apnea caused enhanced intensity and frequency of distressing dreams. The examiner opined that the severe negative sequela to Veteran's substance abuse and personality disorder accounted for the majority of his psychosocial impairment over the years. He noted that the Veteran’s psychiatric symptoms currently attributable to his PTSD included occasional avoidance of crowds, and distressing dreams and ruminative thoughts about combat trauma. The Veteran stated that he did not have symptoms “24/7” and that he was primarily troubled by disturbing dreams. The examiner noted that he managed his condition without medication. He found that the Veteran had occupational and social impairment due to mild or transient symptoms. He remarked that the Veteran's PTSD was 10 percent disabling, and his depressive disorder was 10 percent disabling and most likely related to the negative fallout from antisocial behaviors and substance abuse. The Veteran’s polysubstance abuse was in remission and non-contributory. The examiner concluded that the Veteran’s personality disorder accounted for the remainder of his psychosocial impairment. The Veteran reported that his relationship with his siblings was good, that he had many friends from church, which he had attended three times a week for the last 20 years, and that he played sports. He related that he had a very close relationship with his son and that he had been married to his current wife for approximately 16 years. He presented symptoms of depressed mood; anxiety; suspiciousness; panic attacks that occurred weekly or less often; chronic sleep impairment; and mild memory loss, such as forgetting names, directions or recent events. His thought process was normal, his speech rate and flow was within normal limits, and he was cooperative throughout the examination. He could maintain minimal personal hygiene and other basic activities of daily living, he was oriented, he had normal abstract thinking, and fair memory. He denied any obsessive rituals, and reported fleeting passive suicidal ideation. He reported low energy and nocturnal awakenings every three hours due to nightmares with combat-related content. He did not have significantly impaired impulse control and claimed he heard non-descript voices that were not there. The examiner stated that tests indicated that the Veteran’s performance was consistent with individuals responding in a valid manner, and that the Veteran did not appear to be intentionally exaggerating signs and symptoms of PTSD, or attempting to appear worse off than he was in reality. He was assigned a GAF score of 55. A July 2012 VA examination report reflects the examiner’s conclusion that the Veteran failed to meet the diagnostic criteria for PTSD. The examiner noted that the Veteran had a history of presenting with numerous mental health complaints, which were inconsistent with PTSD. His mental health history also suggested that he tended to over-endorse mental health difficulties with a focus on secondary gains associated with obtaining PTSD diagnosis. The examiner noted that prior examiners had determined that the Veteran had exaggerated his symptoms and that he minimized his substance abuse issues. The examiner also noted that the Veteran had made several contradictory statements throughout the interview, and that his tendency to embellish his military experiences as well as his over-endorsing his mental health issues brought doubt as to his primary mental health difficulties. As such, the examiner found that a diagnosis of PTSD was not suggested. In November 2012, a VA social worker reported that the Veteran had been married five or six times and that he had lost several jobs because he did not get along well with his supervisors and people in general. The Veteran stated that he could not sleep through the night because of nightmares related to his war experiences, and that he heard voices telling him to kill himself. The Veteran had PTSD symptoms like hypervigilance, exaggerated startle response, difficulty concentrating, flashbacks, feeling of detachment, estrangement from others, startle reflex, intrusive and distressing thoughts related to his war experiences, extreme anger and inability to get along with people, and depressed mood. His appearance was neat, his manner was friendly and cooperative, and his intelligence was average. His speech was appropriate and he was oriented to time, place, and person. His memory function was impaired, his affect labile, his judgment was fair, and he had no delusions or hallucinations. He had good recent, remote, and past memory; and he denied suicidal or homicidal ideation associated with his current life circumstance. VA treatment records dated in January 2013 note that the Veteran had difficulty sleeping through the night and was awakened by nightmares related to war. He reported that once he was awake, he was unable to go back to sleep until daybreak. The Veteran also reported that he had flashbacks. An April 2015 VA examiner diagnosed the Veteran with PTSD and unspecified depressive disorder. The examiner opined that while the May 2012 VA examination attributed the Veteran’s depressive symptoms to substance abuse and consequences of substance abuse, the depression had been greatly aggravated by his service-connected medical conditions, to include diabetes and associated neuropathy, kidney disease, and reduced use of his right arm. As such, the examiner found that the Veteran's depression should be considered a secondary service connection and that all impairment noted in the examination should be considered as service-connected. He attributed the Veteran’s symptoms of intrusive memories and nightmares of traumatic events, efforts to avoid trauma memories and trauma reminders, hypervigilance, exaggerated startle response, sleep disturbance, irritability, impaired concentration, and feelings of alienation accompanied by difficulty trusting other to his PTSD. The Veteran’s symptoms of unspecified depressive disorder included depressed mood, reduced energy and motivation, reduced activity level, periodic hopelessness and suicidal thoughts, and anhedonia. The examiner noted that depressive symptoms were common in PTSD, and it was likely that the two conditions interacted significantly. He opined that the Veteran had occupational and social impairment with reduced reliability and productivity, and that it was not possible to differentiate what portion of the impairment was attributable to each diagnosis due to the significant interaction between PTSD and depression. The Veteran reported that he had little contact with his siblings following his mother's death. He was on his sixth marriage with a woman he had been previously married and he described the relationship as supportive. He stated that he had contact with his son and his grandchildren, but that he had no recent contact with his daughter. He reported that he had trouble trusting people and only had one friend. He indicated that he could perform self-care and personal hygiene tasks independently, but often neglected them due to reduced motivation and energy. He reported that other household members did the cooking and cleaning, and that his wife did most of the grocery shopping. The Veteran stated that he spent most of his time at home reading, watching television, or sleeping, but that he would leave the house for necessary appointments or errands, and to visit his son and grandchildren. He indicated that he would sometimes take his grandchildren shopping or to a fast food restaurant drive-through. PTSD symptoms included intrusive memories and nightmares, avoidance of trauma reminders, hypervigilance, and excessive sleep that was frequently interrupted by nightmares. The Veteran reported that he was “easily agitated,” and typically expressed himself verbally or by isolation. He denied recent violent behaviors or thoughts, and complained of problems with concentration, describing himself as increasingly forgetful. He reported low energy, and had no manic or hypomanic symptoms. He acknowledged a history of suicidal ideation, but did not report any history of suicide attempt. At the interview, the Veteran was casually dressed and groomed, with an overweight appearance, and was mildly malodorous. He was well oriented and cooperative, with fair insight. His mood was mildly depressed and affect was appropriate to topic. He appeared preoccupied with attempting to make a good case for increased compensation, but within that context his thought processes were logical and goal directed. His long-term memory appeared functional, but his short-term memory was poor. His concentration was fair and conversational flow was consistent with average to low average verbal intelligence. Based on the consideration of the above-cited evidence, including the VA examination reports and the lay statements of record, the Board finds that the collective lay and medical evidence indicates that an initial rating in excess of 10 percent for PTSD prior to April 8, 2015 is not warranted. Prior to April 8, 2015, the evidence shows that the Veteran exhibited severe psychiatric symptoms, to include delusions, auditory hallucinations, paranoia, depressed mood, concentration and memory problems, social impairment, chronic sleep impairment, and impaired impulse control. In light of the points raised in the March 2018 memorandum decision, the Board notes that service connection for depressive disorder was not established until April 8, 2015, as secondary to other service-connected disorders. The Board acknowledges the holding of the Court in Mitteider v. West, 11 Vet. App. 181 (1998). In accordance with that holding, whenever "it is not possible to separate the effects of the [service-connected condition and the non-service-connected condition], VA regulations . . . clearly dictate that such signs and symptoms be attributed to the service-connected condition.” See id at 182. Further, the April 2015 VA examination, in part, served as the basis for the 70 percent rating, which was assigned as of the date of the VA examination—April 8, 2015. The evidence from that date forward, to include the VA examination report, reflected an inability to separate the functional impacts of the Veteran’s service-connected PTSD and depression from other nonservice-connected psychiatric disabilities—thus, resulting in the 70 percent rating from that date forward. However, prior to that date, the evidence reflects an ability of VA examiners and other mental health providers to distinguish precisely which symptoms were attributable to the Veteran’s PTSD alone. To that end, the Board finds that although the Veteran clearly exhibited severe psychiatric disturbances, the evidence shows that these were primarily a sequela of his substance abuse, his head injury in the 1980s, and his personality disorder. Indeed, the symptoms associated with his service-connected PTSD consisted of avoiding crowds and distressing dreams about combat trauma. Collectively, these symptoms are of the type and extent, frequency and/or severity (as appropriate), to suggest occupational and social impairment due to mild and transient symptoms-the level of impairment contemplated in the 10 percent rating. The August 2010 and May 2012 VA examiners both noted the Veteran’s history of a head injury in the 1980s as well as the Veteran’s history of substance abuse. The August 2010 VA examiner specifically found that the Veteran’s profound social and occupational impairments could be fully attributed to his substance abuse, personality disorder, possible sequela from his head injury in the early 1980s, and what appeared to be substance-induced psychosis. Based on such, he opined that the origin of the Veteran’s impairment did not appear to be related to his military service. Likewise, the May 2012 VA examiner found that the severe negative sequela of Veteran’s substance abuse and personality disorder accounted for the majority of his psychosocial impairments over the years, and that the symptoms attributable to his PTSD were occasional avoidance of crowds, and distressing dreams and ruminative thoughts about combat trauma. Notably, the May 2012 VA examiner opined that the Veteran had occupational and social impairment due to mild or transient symptoms and concluded that his PTSD was 10 percent disabling, that his depressive disorder was 10 percent disabling and most likely related to the negative fallout from antisocial behaviors and substance abuse, and that his personality disorder accounted for the remainder of his psychosocial impairments. In addition, the April 2012 VA physician noted that while the Veteran appeared paranoid, this was a personality trait with significant externalizing. Further, VA physicians and examiners noted that the Veteran was inconsistent, exaggerated his symptoms, and was very focused on his entitlement to benefits. The August 2010 VA examiner noted that there were clear indications of symptom exaggeration, which brought the Veteran's credibility into question, and remarked that he was very intense and focused on his entitlement to benefits. Similarly, the April 2012 VA physician noted that the Veteran stated that he was highly intelligent and competent to manage his money, but then stated that he was having severe memory problems. The physician specifically remarked that he was unable to reconcile the inconsistencies in the Veteran’s self-reports. Likewise, the July 2012 VA examiner noted that the Veteran had a history of presenting with numerous mental health complaints which were inconsistent with PTSD and that the Veteran’s tendency to embellish his military experiences, as well as over-endorsing his mental health issues, with a focus on obtaining benefits, brought doubt as to his primary mental health difficulties. For the period prior to April 8, 2015, the Board acknowledges the Veteran’s assigned GAF scores of 45 (in September 2009), 35 (in November 2009), and 55 (in May 2012), and notes that, per the DSM-IV, such suggest moderate to serious symptoms, or moderate to serious difficulty in in social, occupational, or school functioning. Such scores are thus indicative of a greater level of impairment than is contemplated in the assigned 10 percent rating. The Board reiterates, however, that while the Veteran clearly suffered from severe psychosocial problems, the record includes competent, probative evidence indicating that the vast majority of such problems stemmed not from his service-connected PTSD, but from his personality disorder and sequela of substance abuse and head injury. For the period from September 2, 2009, to April 8, 2015, as discussed above, the Veteran’s symptoms attributable to his service-connected PTSD more closely approximated a 10 percent disability rating during the period. In sum, the Board finds that, prior to April 8, 2015, the Veteran's PTSD resulted in psychiatric symptoms of the type and extent, frequency, and/or severity, as appropriate, to indicate the level of impairment contemplated in the assigned 10 percent, but no higher, rating. In reaching the above conclusions, the Board is mindful that the symptoms listed in the rating schedule are essentially examples of the type and degree of symptoms indicative of the level of impairment required for each such rating, and that the Veteran need not demonstrate those exact symptoms to warrant a higher rating. See Vazquez-Claudio and Mauerhan, supra. The Board has not required such symptoms when evaluating the disability at issue for the period in question considering his rating of 10 percent prior to April 8, 2015. For all for the foregoing reasons, the Board that an initial rating for PTSD greater than 10 percent, prior to April 8, 2015, is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher rating during the period under consideration, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). II. TDIU The Veteran filed his claim for a TDIU on October 14, 2009. Under the applicable criteria, total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). When the percentage requirements for a schedular TDIU rating under 38 C.F.R. § 4.16(a) are not met, a total rating, on an extra-schedular basis, may be granted, in exceptional cases (and pursuant to specifically prescribed procedures), when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability(ies). See 38 C.F.R. § 4.16(b). The central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran’s education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether a veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, 4 Vet. App. at 363. In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Veteran has been awarded service connection for the following: nephropathy with hypertension associated with DM (rated at 20 percent from July 7, 2008; 60 percent from October 31, 2011; and 80 percent from May 22, 2013); PTSD (rated at 10 percent from September 2, 2009 and at 70 percent from April 18, 2015); DM with cataracts, retinopathy, and erectile dysfunction (rated at 20 percent from May 8, 2001), right shoulder disability (rated at 20 percent from August 11, 2008); right lower extremity neuropathy, sciatic nerve (rated at 10 percent from July 7, 2008 and 20 percent from August 14, 2013); right upper extremity neuropathy associated with DM (rated at 20 percent from August 14, 2013); left upper extremity neuropathy associated with DM (rated at 20 percent from August 14, 2013); left lower extremity neuropathy (rated at 10 percent from July 7, 2008); right lower extremity neuropathy, femoral nerve, associated with DM (rated as 10 percent from August 14, 2013); left lower extremity neuropathy, femoral nerve, associated with DM (rated at 10 percent from August 14, 2013); hypertension associated with DM (rated at 10 percent from July 7, 2008); bilateral hearing loss (rated as noncompensable from December 9, 1997; ar 10 percent from April 30, 2008; at 20 percent from August 20, 2009; and at 10 percent from March 1, 2012); right shoulder scar (rated as noncompensable from August 11, 2008); and scar above the right eye (rated as noncompensable from April 13, 2010). The combined disability rating was noncompensable from December 9, 1997; 30 percent from May 8, 2001; 40 percent from April 30, 2008; 60 percent from July 7, 2008; 80 percent from September 2, 2009; 90 percent from October 31, 2011; 80 percent from March 1, 2012; 90 percent from May 22, 2013; and 100 percent from August 14, 2013. As noted, the percentage requirements for a schedular TDIU were met as of the date of filing of the Veteran's October 14, 2009, claim for a TDIU. See 38 C.F.R. § 4.16(a). The remaining question, then, is whether competent, probative evidence establishes that the Veteran’s service-connected disabilities rendered him unemployable during the period from October 14, 2009 to August 14, 2013. The evidence shows that the Veteran obtained an Associate’s degree in political science and worked as a circuit designer for a telephone company for 12 years. Although there is some conflicting evidence regarding the Veteran’s employment history, it appears he has not had substantially gainful employment since the 1980s. VA treatment records in September 2009 reveal that the Veteran resigned from his work after he was kidnapped and assaulted while onsite and that he had been unable to work in 20 years after what the physician believed to be a psychotic episode while on the job. However, later statements from the Veteran during treatments and at his May 2016 hearing show that he temporarily worked as a security guard and at a McDonalds. However, in both instances, the Veteran was let go due to anger management and conflicts with his supervisors and co-workers. A November 2009 VA examination report indicates that the Veteran’s medical conditions were stable and did not interfere with his ability to be employed. Specifically, the examiner stated that he was able to ambulate and could perform a desk job. An August 2011 VA examiner found that the Veteran’s right shoulder disability impacted his ability to work because the pain increased with any use of the arm. A May 2012 VA examiner found that the Veteran’s Metabolic Equivalent for Tasks (METs) was consistent with activities such as light yard work (weeding), mowing lawn (power mower), and brisk walking (4 mph). The examiner found that the impact was 50 percent due to his nonservice-connected heart condition and 50 percent due to his diabetes with peripheral neuropathy. Further, the Veteran’s hypertension did not impact his ability to work. In addition, as detailed above, during this time period the Veteran's service-connected PTSD symptoms primarily consisted of avoidance of crowds and sleep impairment. An August 13, 2013 VA treatment record notes that the Veteran suffered, among other things, from PTSD, DM, hypertension, and chronic kidney disease (CKD) with nephrotic syndrome. The physician found that the Veteran's DM was stable and better controlled with insulin and diet, and that his hypertension and CKD were stable. He found that in light of all the above medical problems and complications, to include service-connected and nonservice-connected disabilities, the Veteran was to be considered unable to be work and totally disabled for the rest of his life. Considering the above-cited evidence in light of the applicable legal authority, the Board finds that the evidence shows that prior to August 14, 2013, the functional impairment caused by the Veteran’s service-connected disabilities did not render him unable to obtain and retain substantially gainful employment. The Board acknowledges that the ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator. See 38 C.F.R. § 4.16(a). See also Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev’d on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). However, medical evidence addressing the functional effects of the Veteran's disability(ies) on his ability to perform the mental and/or physical acts required for substantially gainful employment is relevant to the unemployability determination. See 38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). Here, prior to August 14, 2013, the Veteran was service connected for nephropathy with hypertension associated with DM; PTSD; DM; right shoulder disability; peripheral neuropathy of the right and left lower extremity; hearing loss; right shoulder scar; and scar above his right eye. The weight of the evidence for that period indicates that the Veteran's service-connected disabilities did not render him unemployable. As noted, the November 2009 VA examiner found that his medical conditions were stable and did not interfere with his ability to be employed. Notably, the examiner opined that the Veteran could perform sedentary work. Further, while the August 2011 VA examiner opined that the Veteran’s right shoulder disability impacted his ability to work because the pain would increase with any use of the arm, the May 2012 VA examiner noted that the Veteran’s METs were consistent with the ability to perform light work. Although the Veteran suffered from severe psychiatric problems during this period, the Board notes that the majority of his symptoms were due to nonservice-connected psychiatric disorders. Indeed, as stated above, his service-connected PTSD symptoms mainly consisted of avoiding crowds and sleep impairment, which the May 2012 VA examiner noted resulted in occupational and social impairment with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. It was not until August 13, 2013, that the Veteran was considered unable to be work and totally and permanently disabled. Collectively, this evidence preponderates against an award of a TDIU prior to that date. In addition to the medical and other objective evidence discussed above, the Board also has considered the Veteran's own assertions advanced in support of his claim. The Veteran, as a lay person, is certainly competent to report matters within his own personal knowledge, such as his own symptoms, and the reasons why he stopped working. See, e.g., Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, when assessing credibility and probative value, such assertions must be weighed against medical and other pertinent evidence. Cf. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Here, the Veteran has offered inconsistent statements regarding the reason for his retirement and the impact of his symptoms when he was working. As reflected in statements from February 2012 and September 2014, the Veteran asserted that he stopped working in the 1980s due to his right shoulder disability and his PTSD symptoms. In September 2014, the Veteran also stated that he stopped working in 2002 due to his right shoulder disability, PTSD, diabetes mellitus, and kidney disability. At this May 2016 hearing, the Veteran stated that he stopped working because of his right shoulder disability, which would pop out of place any time he tried to reach for something. However, VA treatment records in September 2009 note that the Veteran resigned from his work after being kidnapped and assaulted on the job, and that he had been unable to work for 20 years after he had suffered what appeared to have been a psychotic episode. Here, the Board finds that the Veteran’s statements made in September 2009 that he resigned due to his kidnap and assault while on the job, made prior to his VA claim for a TDIU, are more probative than the statements made after October 2009 (apparently, in furtherance of his claim for monetary benefits) to the effect that he stopped working due to his service-connected right shoulder disability and PTSD (and later his diabetes and kidney disabilities). See White v. Illinois, 502 U.S. 346, 355-56 (1991) (holding that statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment). See also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (a pecuniary interest may affect the credibility of a claimant's testimony). Furthermore, to whatever extent the Veteran attempts to establish that he was rendered unemployable due to service-connected disabilities on the basis of his own lay assertions, the Board emphasizes that he is not shown to possess any expertise in medical or vocational matters so as to competently opine on such a matter (see, e.g., 38 C.F.R. § 3.159 and Bostain v. West, 11 Vet. App. 124, 127 (1998)), and, as indicated above, the persuasive medical and other objective evidence on this point simply does not support such an assertion. Given the entirety of the evidence of record, the Board finds that the resulting functional impairment from the Veteran’s disabilities was not shown to be so severe as to preclude all forms of substantially gainful employment prior to August 14, 2013. In short, the weight of the competent, probative evidence indicates that those service-connected disabilities did not render the Veteran unemployable at any point pertinent to this period. Accordingly, the claim of entitlement to a TDIU for the period prior to August 14, 2013, from must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Michael Sanford, Counsel