Citation Nr: 1817641 Decision Date: 03/22/18 Archive Date: 04/03/18 DOCKET NO. 14-29 556 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to February 3, 2017, and a rating in excess of 70 percent thereafter, to include entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and B.G. ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel INTRODUCTION The appellant served on active duty in the Marine Corps from September 1971 to December 1973, including service in the Republic of Vietnam. He is the recipient of the Good Conduct Medal. This matter comes before the Board of Veterans' Appeals (Board) from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. Jurisdiction was subsequently transferred to the RO in Roanoke, Virginia. The appellant filed a timely Notice of Disagreement (NOD), received in August 2013. A Statement of the Case (SOC) was issued in June 2014. Although the June 2014 SOC discussed six issues, the substantive appeal, received in August 2014, was limited to the PTSD issue. A March 2017 rating decision increased the evaluation of PTSD from 50 percent to 70 percent, effective February 3, 2017. As such was not a full grant of the benefit sought on appeal, a Supplemental Statement of the Case (SSOC) was issued in March 2017. The appellant was afforded a central office hearing before the undersigned in June 2017. A transcript is of record. FINDING OF FACT The appellant's PTSD is manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but not total occupational and social impairment, nor does the appellant's PTSD render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 70 percent, and no higher, for PTSD have been met or approximated for the period on appeal. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2017). 2. The criteria for entitlement to TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 3.1010, 4.1, 4.2, 4.3, 4.10, 4.15, 4.16 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) Neither the appellant nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Applicable Law Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the denial of a claim of an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA's adjudication of the claim for increase is lengthy, and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different, or "staged," ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Under the rating criteria for mental disorders, a 70 percent evaluation is warranted for PTSD manifested by 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 the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9400. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In Maurehan v. Principi, 16 Vet. App. 436 (2002), the U.S. Court of Appeals for Veterans Claims held that the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the evidence considered in determining the level of impairment under section 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, a GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV)). However, GAF scores have been removed from the DSM-5. A GAF score of 61 to 70 represents mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51 to 60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with coworkers). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or a major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). Lesser scores reflect increasingly severe levels of mental impairment. American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, 4th Ed. (1994) (DSM-IV). While particular GAF scores are not contained in the VA schedule of ratings for mental disorders, they are a useful tool in assessing a veteran's disability and assigning ratings. 38 C.F.R. § 4.130. However, they are just one of many factors considered when determining the appropriate rating. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." See Gilbert, 1 Vet. App. at 54. III. Background An August 2010 clinical note states that, although the appellant was feeling calmer, a recent automobile accident had rekindled his hyperarousal and he was feeling more jumpy, particularly while driving. Thoughts of hopelessness, helplessness, and worthlessness were denied. Nightmares caused insomnia, but he felt that such were less intense and frequent. Examination revealed casual dress and good hygiene. Mood was "OK edge but slightly better." Affect was mildly restricted. Speech was of normal rate, volume, and tone; and thought process was logical and goal-directed. There was no suicidal or homicidal ideation, intent, or plan. There were no hallucinations or paranoia. Hyperarousal was endorsed. Depressive symptoms were denied. Judgment and insight were fair to good; and he was oriented to all spheres. The appellant was afforded a VA examination in August 2010. The claims file was reviewed. The appellant reported three psychiatric hospitalizations. In 2001, he was hospitalized for PTSD-related symptoms including night sweats, sleep disturbance, hypervigilance, panic attacks, nightmares, and flashbacks. His 2002 hospitalization was for the same symptoms. His third hospitalization occurred two years prior to the instant examination and was due to homicidal ideation, sleep disturbance, flashbacks, and nightmares. The appellant endorsed current symptoms of sleep disturbance, hypervigilance, difficulty trusting others, anger, poor impulse control, constant nightmares, and occasional flashbacks. He worked as a construction contractor but had not worked in the past three months. However, such lack of employment was not due to his PTSD. He reported that his relationships with his children were excellent and that he was actively involved in their lives. He occasionally interacts with family and friends, although he prefers to be alone so he will not get into trouble. His family must call him to initiate contact. Due to tight finances, he endorsed an inability to have much of a social life. Verbal confrontations were reported, although such were rare. Three weeks prior, he got into a verbal confrontation with a stranger, but he was able to walk away. The appellant was noted to appropriately interact with others and be capable of performing basic activities of daily living, meeting family responsibilities, meeting work demands, and meeting work responsibilities. The examiner noted that employment, activities of daily living, routine responsibilities, physical health, and schooling were not currently affected by the appellant's PTSD symptoms. However, there were moderate effects on his family role, relationships, leisure activities, and quality of life. Examination revealed that the appellant was neat, clean, and dressed appropriately for the season. There was no sign of psychomotor retardation or aggravation. There was impairment of thought process or communication in that he reported he was paranoid and suspicious of others. He had difficulty trusting others. When queried regarding delusions and hallucinations, the appellant reported that he constantly heard a voice that asked "what would it be like to jump out this window or to drive off this bridge?" However, the examiner stated that there were no delusions or hallucinations. Behavior during the session was appropriate. The appellant endorsed passive suicidal ideation when he was sleep-deprived, but he denied plan or intent. The appellant was able to maintain personal hygiene and perform basic activities of daily living. He was oriented to all spheres. With respect to memory, he endorsed difficulty recalling things from time to time. He frequently forgot where he parked his car or left a tool. He also had difficulty recalling directions and appointments. There were no obsessive or ritualistic behaviors which interfered with routine activities. Rate and flow of speech were normal. Panic attacks were endorsed, which could occur at any time. Such included shortness of breath, sweats, tension, and heart palpitations. They mostly occur when he is in a closed area which reminds him of when he was trapped under a car. It takes approximately 20 minutes for him to get himself together and another 10 to mobilize himself. He also stated that he feels he may pass out during such episodes. Depressed mood, anxiety, and depression were present. Impaired impulse control was endorsed. He explained that he reacts without thinking about the consequences of his behavior. He cannot predict his behavior, which is situation-dependent. Sleep impairment was endorsed. He reported getting approximately three hours of sleep per night. He wakes up in the middle of the night and cannot fall back asleep. He is easily awakened. It takes a couple of hours for him to fall asleep. Nightmares occur almost every night. Night sweats were also endorsed. The examiner noted that the appellant's symptoms were chronic, continuous, and moderate to severe. There was no remission. The examiner opined that the appellant's employability was fair and that he was not unemployable. A GAF score of 50 was assigned. He was capable of managing his own benefit payments. The prognosis for improvement was fair. The appellant was afforded a VA examination in October 2011. A GAF score of 50 was assigned. The examiner opined that the appellant experienced occupational and social impairment with reduced reliability and productivity. The appellant was still married but had been separated from his wife for 10 years. He stated that "[the relationship] might have a chance, if [he] can learn to trust." He noted that he still supported his wife financially but "still [had] some issues [he needed] to address." He reported one close friend in his building, a fellow veteran, who helps him manage his symptoms of anger and PTSD. The appellant's physical problems precluded him from being as active as he wanted to be, although he was performing rehabilitation exercise. He stated that he attends church weekly, enjoys spending time with his grandchildren, and that his daughter is his "number one support." He noted that he worked as a construction contractor and that his supervisor affords him flexibility due to his pain. Work was consistent because he tries to be a "people person." He also held a part-time paid position pulling records. He reported a recent panic episode early in the morning. In May 2011, he presented to the emergency room with chest pains and shortness of breath. A psychiatrist held him overnight for observation; however no underlying medical etiologies could be determined. Panic attacks typically last from 30 minutes to one hour, and occur sporadically, as often as three times a week. There were no known triggers. He uses relaxation strategies and contacts his veteran friend to cope. The appellant reported ongoing anger issues whenever he perceived a threat. He described an instance recently when a neighbor helped him when he forgot his keys. However, a verbal argument ensued when the appellant felt he was being taken advantage of when the neighbor requested financial compensation for the favor. He endorsed homicidal ideation towards the neighbor but did not act on such as the neighbor walked away from the conflict. Also recently, the appellant was cut off by someone in the parking lot of a fast food establishment. The stranger stared the appellant down. The appellant exited his car and a verbal argument ensued. He was held back by a companion. The appellant reported homicidal ideation towards the stranger and drove an hour out of his way to calm down. He denied additional homicidal thoughts, or thoughts of harm, toward these individuals. The appellant explained that he removed himself from situations in order to avoid conflict. The threat of being incarcerated motivates him to avoid such situations. While his homicidal thoughts were not premeditated, he had problems controlling his anger in the moment. Continued problems sleeping were endorsed; however, he stated that he had never had a good night's sleep. Such resulted in fatigue. He reported nightmares several times per week, including a recurring dream where a Vietnamese soldier chases and kills him. Intrusive thoughts regarding his Vietnam service were endorsed, which were triggered by diesel fuel and seeing military fatigues. The appellant had been clean and sober since 2001. Further legal and behavioral problems were denied. The examiner noted depressed mood, anxiety, suspiciousness, panic attacks more than once weekly, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, impaired judgment, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. A June 2012 clinical note states that the appellant endorsed low energy and interests. He endorsed a passive death wish one month prior but denied suicidal ideation. He recently submitted retirement papers. Social support was noted to be less than adequate. He had a close relationship with his daughter and with a fellow veteran in his building. His daughter and ex-wife helped with shopping. He had not recently experienced nightmares. Hypervigilance and startle reaction were endorsed. He avoided social situations. He was casually dressed and pleasant, and walked with a cane. Cognitive functioning and eye contact were good. Motor function was notable for walking slowly with a cane; however, there were no abnormal movements. Mood was 8/10 and affect was calm. Speech was of normal rate, volume, and tone. Thought process was goal-oriented. There were no delusions or hallucinations. Insight and judgment were good. There was no suicidal ideation, intent, or plan. The clinician noted that the appellant was stable and had improved since the last session in February 2012. A GAF score of 70 was assigned. In a statement received in November 2012, the appellant reported that he had quarterly psychiatric appointments and that his medication had recently been adjusted because his symptoms had increased in severity. A statement from D.G. was received in November 2012. She had known the appellant for three years and stated that she had to help the appellant with daily activities such as house-cleaning and bathing. She stated that the appellant's rheumatoid arthritis had worsened and precluded him from being able to move around. A statement from the appellant's daughter was received in November 2012. She stated that the appellant has trouble with moving around and performing activities of daily living, including daily hygiene, getting dressed, and cooking, as a result of his foot and knee operations and his rheumatoid arthritis. She stated that he is unable to go to work on a regular basis now. A May 2013 clinical note states that the appellant retired in May 2013 because he did not feel that he could work on ladders or at a construction site. He endorsed anxiety attacks and sometimes sleeps poorly. He stays connected with his daughter and friends. Mood had been 40 percent of normal over the past month. Interrupted sleep of four to five hours per night was endorsed. Energy and interests were lower than usual. There had been no suicidal ideation, homicidal ideation, or passive death wish in the past year. He tended to stay by himself, which restricts activities. Anxiety was mild in the past month. Examination revealed a casually dressed and pleasant man. Cognitive functioning and eye contact were good. Motor function was notable for walking slowly with a cane; however, there were no abnormal movements. Mood was 4/10 and affect was calm. Speech was of normal rate, volume, and tone. Thought process was goal-oriented. There were no delusions or hallucinations. Insight and judgment were good. There was no suicidal ideation, intent, or plan. The clinician noted that the appellant was stable even though he had not been seen for one year. A GAF score of 60 was assigned. An August 2013 clinical note states that the appellant experienced nocturnal panic attacks almost every night. He endorsed feeling pressure on the chest upon awakening, shortness of breath, diaphoresis, and numbness and tingling of the lower extremities. Such had been occurring for a month. He endorsed an increase in the intensity of his hypervigilance. Suicidal ideation was noted; however, there was no intent or plan. Homicidal ideation was denied. Prior thoughts of harming himself were noted, although he had not followed through on such. A GAF score of 50 was assigned. The examiner described the appellant as presenting with overwhelming anxiety. A September 2013 clinical note states that the appellant was admitted to the psychiatric unit on September 5, 2013, and was discharged on September 12, 2013. Upon admission, a GAF score of 35 was assigned. At discharge, his GAF score was 65. He was referred from the mental health clinic after he endorsed feeling low, having suicidal ideations, and having homicidal ideations toward his ex-wife. Upon admission, he was cooperative with the clinician. Speech was loud and rapid, but easily interruptible and of normal rhythm. Mood was "OK." Affect was dysphoric and irritable. Thought process was linear and goal-directed. Thought content was preoccupied with being cheated by his ex-wife. Hallucinations were denied. Cognition was grossly intact. Insight was fair and judgment was poor. He experienced nightmares while admitted, but not on the final night. Mood improved during the appellant's stay. Suicidal ideation was resolved upon admission. The appellant endorsed thoughts about hurting his ex-wife for a couple of days into admission; however, such resolved on the fourth day. His cousin, B.G., indicated that the appellant's knife collection had been disposed of. Anxiousness dissipated throughout the admission. He was not a behavioral problem on the unit; rather, he was cooperative with the staff and treatment team throughout his stay. Upon discharge, he was awake and cooperative. Cognitive functioning was grossly intact and eye contact was good. There were no tremors or involuntary movements. Mood was good and affect was euthymic. Speech was spontaneous and of normal tone, rate, and volume. Thought processes were linear and goal-oriented. There were no delusions elicited. Hallucinations were denied. Suicidal and homicidal ideation was denied. Insight and judgment were good. A September 2013 clinical note states that the appellant was status post inpatient mental health admission. He stated that his mood had been approximately 3-4/10. He endorsed continued lightheadedness, headache, and nausea, which started when he first came to the mental health clinic before being admitted. Such symptoms have improved but were still noticeable. Sleep still included frequent awakenings. He denied suicidal or homicidal ideation. He stated that his daughter was planning to assist him with the financial problem which led to the mental health admission. Examination revealed fair grooming with facial stubble, the wearing of a hat, and a calm, pleasant, and cooperative man. Cognitive functioning was grossly intact. Eye contact was good. There were no tics or tremors. Mood was a "little better" and affect was of full range and appropriate. Speech was spontaneous and mildly pressured, but of normal volume. Thought processes were linear and goal-oriented. He denied suicidal and homicidal ideation and there were no delusions or paranoia noted. It was unclear if the appellant was experiencing visual hallucinations of mice or if they were real. Insight and judgment were fair. The examiner noted that the appellant had been recently admitted to inpatient mental health with low mood. There had been suicidal and homicidal ideation in the context of a financial dispute with his wife. His mood was now stable following discharge; and there had been some conflict resolution thanks to his daughter's mediation. A GAF score of 65-75 was assigned. A medical opinion was offered from Dr. C.J. in October 2013. Dr. C.J. stated that he was the appellant's primary treating physician for his service-connected PTSD. Private hospital and treatment records were reviewed. Dr. C.J. opined that the appellant was unemployable due to his service-connected disabilities because he had impairment of the mind or body from his service-connected PTSD which rendered it impossible for the average person to follow a substantially gainful occupation. Dr. C.J. explained that the appellant was unable to work due to the severity of his PTSD symptoms and depression. He had difficulty with anger, mood problems, sleep problems, and an inability to be around people. In October 2013, Dr. V.H.P. stated that he was the appellant's primary care provider for his psychiatric problems. He had treated the appellant for two months. Dr. V.H.P. opined that the appellant experienced occupational and social impairment with reduced reliability and productivity, and occupational and social impairment with deficiencies in most areas. The most prevalent symptoms included nocturnal panic attacks, anxiety, disturbance of mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. Dr. V.H.P. opined that the appellant was unemployable due to his service-connected PTSD. He assigned a GAF score of 50, and noted that the appellant's GAF score had been 55 in the past year. In a statement dated December 2012 but received in December 2013, the appellant stated that, although his retirement was supposed to be effective October 2012, the paperwork has not been completed by his employer. He stated that he misses more time from work than he actually works during the week. His employer has accommodated him by reassigning him to a primarily sedentary position. However, he is still unable to be productive. A home healthcare provider from VA must come to his home on occasion to assist with daily activities of living including bathing, washing clothing, and eating. He also receives help from family and friends due to difficulties standing or walking for long periods. His income was not sufficient due to his inability to work consistently. He contended that he is unable to secure or follow any substantially gainful occupation due to his service-connected disabilities. A December 2012 earning statement, contemporaneously submitted, indicates that he used 665 hours of leave without pay and 480 hours of family leave in 2012. A From 21-8940 was received in December 2013. The appellant reported that his rheumatoid arthritis and total knee replacement prevented him from securing or following any substantially gainful occupation. He noted a foot operation in April 2011 and a knee replacement in March 2012. His disability affected full-time employment, he last worked full-time, and he became too disabled to work on October 15, 2011. He had worked full-time as an archives technician since March 2001. He stated that he lost 1259.5 hours due to illness. He did not leave his last job due to his disability; and he had not attempted to obtain employment since he became too disabled to work. He reported a four-year high school education, but denied any other training or education. In his substantive appeal, received in August 2014, the appellant stated that he had multiple hospital admissions for mental health problems. He stated that, each time he is seen by a different clinician, it is traumatizing to report his experiences again and again. He explained that, in September 2013, he was hospitalized after severe thoughts of revenge, homicide, and suicide. Prior to admitting himself, he plotted, planned, and attempted to figure out ways to ensure that no one, including his wife, could take advantage of him again. During this time, he found places to observe his wife's comings and goings. He endorsed problems with loud and sudden noises and that he must retreat to quiet places. He reported hypervigilance when in public. He must sit facing the front exits with his back to the wall, such that he can observe everything and everyone. He stated that, while volunteering in July and August 2014, he carried three bodies to a morgue. On each occasion, he experienced anxiety attacks, sweating, and shortness of breath. Since such time, he has experienced recurring nightmares and thoughts. Thus, he sought medical attention in August 2014. An October 2014 clinical note states that the appellant reported family conflict at home. He was upset with his daughter and grandchildren not cleaning up after themselves, eating his food without permission, being disrespectful towards him, and his daughter locking him out of his home. Such escalated to a verbal and physical altercation. His daughter called the police, who told the appellant that if it happened again, he may end up in jail due to his history of past assaults. The appellant stated that his daughter and grandchildren have since moved out. Examination revealed that the appellant was dressed appropriately and was cooperative. He was alert and oriented to all spheres. Eye contact was poor. There were no tics, tremors, or involuntary movements. Mood and affect were depressed and anxious. Speech was logical and coherent. Thought processes were organized. Suicidal and homicidal ideation was denied. Insight was fair and judgment was intact. A GAF score of 60 was assigned. GAF scores assigned between August 2014 and January 2017 ranged from 55 to 60, although the scores were primarily 60. The appellant was afforded a contracted examination in February 2017. The claims file was reviewed. The appellant reported that other medical problems, including foot and leg operations, chronic left leg pain, and rheumatoid arthritis with flare-ups, negatively impact his mood. However, such problems have "slowed him down from his anger issues." The examiner opined that the appellant experienced occupational and social impairment with deficiencies in most areas. The appellant explained that he and his wife divorced in 2011 after "fighting badly," during which he would punch holes in walls. He relapsed on drugs and his wife was also a user. They had been married since 1973. The appellant had not spoken to his daughter and granddaughter in two years, although he is now closer to his other children. He lost four siblings since 2011. He currently lives with his girlfriend, who "takes care of [him]." He has one friend in his building, a fellow veteran. The appellant endorsed suspiciousness with supervisors and "problems with authority." He stated that he attempted to work in a compensated work therapy (CWT) program, but "people were trying to stop [him] from working." He works part-time for pay, but has been "written up" for "petty things" and is unsure how much longer the job will last. He hopes to work more when his leg has healed but is not optimistic due to health problems. He reported that, four years prior, he checked himself into the psychiatric unit at the VA Medical Center and stayed for nine to ten days after beating a man who said the appellant cut him off and called the appellant a name. At the time, the appellant was unconcerned about the man's injuries, but was concerned about his violence, so he checked himself in. He reported nearly experiencing a similar incident with a supervisor, but he stopped himself before acting. He denied a legal history. After he beat the man, he feared arrest so he left the scene, although he denied being arrested. Since inpatient treatment in 2001, he has been clean and sober. He also quit smoking at such time. The examiner noted anxiety, suspiciousness, chronic sleep impairment, flattened affect, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. During the June 2017 Board hearing, the Veteran's representative observed that a longstanding pattern of anger and rage was reported during the February 2017 examination. It was noted that the appellant once checked himself into a hospital. The appellant described an incident approximately two years prior when he nearly hit a cyclist. After the cyclist yelled at him, the appellant testified that he went blank, got out of his vehicle, beat the cyclist down, got back into his vehicle, and quietly drove home. He explained that he viewed the cyclist as if he was a soldier in Vietnam, but that his behavior during the incident was out of character for him. He explained that he also felt rage and anger toward his bosses at work when they picked on him. The appellant was unable to find a place to vent, but felt a desire to hurt his boss. Thus, he quit his job because he would have harmed his boss otherwise. The appellant confirmed that, had he stayed in the job, his boss would have been in imminent danger. This also occurred approximately two years prior to the hearing. B.G. testified that, prior to February 2017, the appellant experienced suicidal ideation. B.G. explained that the appellant told her he wanted to kill himself. He also told her he wanted to jump out of a window or a car. He opened the door while driving on occasion; and she changed the subject to try to get him to calm down. She explained that such had been going on for several years. The appellant reported experiencing hallucinations that he did not remember. However, B.G. observed him experience such and told him about them later. On one occasion, the appellant left the house and walked around, thinking he was still in the house, but he had no clothing on. B.G. explained that she could not find the appellant when he was supposed to be in bed. She explained that there were many occasions where the appellant's mind "blanks" and he thinks he is in one room of the house, while he is in a completely different place. The appellant explained that he was surprised when he was told he had been outside without clothing overnight. He also endorsed feelings of disorientation. The appellant also stated that there was an occasion when he and his ex-wife were experiencing problems prior to their 2011 divorce when the appellant felt a desire to put her in his car and drive off of a bridge. However, he was aware that he needed assistance as a result of these feelings, so he sought help. Periods during which the appellant experienced an inability to perform activities of daily living could last days or weeks. B.G. testified that, on many days, she has to wash, bathe, and feed the appellant because he otherwise is just lying in bed because he is "out of it." She explained that the appellant lived on a street with lots of traffic. The appellant often feels like he is back in a war zone due to vehicle noise and will lock himself in the bathroom and hide in the tub. B.G. has observed the appellant talking to himself during such episodes. The appellant reported an occasion where he recently was asked by a VA clinician who the president was, and he believed that it was still Ronald Reagan. The appellant also explained that there have been occasions where he did not know the names of his nephews, whom he knows quite well. He also could not remember the name of a co-worker with whom he had worked for 14 years, so he called her by nicknames inappropriate for a work environment. This resulted in him being sent to sexual harassment training. The appellant reported that he retired earlier than he wanted to because of multiple operations on the bilateral legs. He stated that a doctor recommended he not return to work. B.G. reported that the appellant suffers from anxiety attacks when he experiences pain from other disabilities. During such episodes, he is unable to function. The appellant reported feeling like his bosses and co-workers were conspiring against him. He stated that he always has a problem with a boss or a job, but is unable to take responsibility and ask himself what part he may have played in creating the problems. He also explained that, approximately five years following separation from service, he went through eleven jobs during one year. He denied finding work afterward which offered stability. Rather, he became homeless for seven to eight years until he tired of being hungry. He took himself to a VA hospital for assistance in 2001, and was checked in for approximately two years and two months. He was released in 2003. IV. Entitlement to an Increased Rating for PTSD The Board finds that the evidence is in relative equipoise as to whether the manifestations of the appellant's service-connected PTSD met or approximated the criteria for a 70 percent rating due to occupational and social impairment with deficiencies in most areas. At no point, however, did the appellant exhibit gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for own occupation or own name. With respect to his August 2010 report that he heard a voice inquiring what the result of jumping out of a window or driving off a bridge would be, the examiner stated that such was not a manifestation of a delusion or hallucination. The Board affords the examiner's opinion great probative weight. June 2012, May 2013, and September 2013 clinical notes were negative for the presence of delusions or hallucinations, although the September 2013 clinician stated that it was unclear whether the appellant was hallucinating mice or whether they existed. During the June 2017 hearing, the appellant and B.G. described hallucinations in which the appellant thought he was in one place but was really in another. However, the preponderance of the evidence is against the appellant experiencing persistent hallucinations or delusions because the evidence indicates that such are not frequent. Further, the instances described during the June 2017 hearing during which the appellant thinks he is in one place but really is in another appear to be episodes of spatial disorientation, a criterion associated with a 70 percent rating. Even if the instances described in the June 2017 hearing were considered hallucinations, a rating in excess of 70 percent would not be warranted because such instances did not occur frequently and because his overall disability picture does not more nearly approximate a 100 percent rating. With respect to memory, the appellant has competently reported difficulty recalling things from time to time. He frequently forgot where he parked his car or left a tool. He also had difficulty recalling directions and appointments. He also reported forgetting the names of nephews he knew quite well, and the name of a co-worker whom he had known for 14 years. He recently was under the impression that Ronald Reagan was still the president. The October 2011 VA examiner described his memory loss as mild. There is no evidence, nor does the appellant contend that he forgets his occupation or name, or the names of his children, siblings, or ex-wife. Thus, the Board finds that such does not more nearly approximate memory loss for names of close relatives, own occupation, or own name. Even if this memory loss did more nearly approximate the 100 percent criteria regarding memory if his nephews were considered close relatives, the appellant's overall disability picture does not more nearly approximate a 100 percent rating. A 70 percent rating, and no higher, is warranted because the evidence shows impaired impulse control, such as unprovoked irritability with periods of violence, and suicidal ideation. There are also instances of homicidal ideation. However, there is no persistent danger of hurting self or others. The appellant described multiple instances during which he got into verbal altercations with others when they upset him. He has become physically violent towards strangers following exchanges of words. The appellant has experienced suicidal and homicidal ideation off and on throughout the period on appeal. These symptoms are sufficient to support an award of a 70 percent rating. However, such did not rise to the level of persistent danger of hurting self or others. In August 2010, he explained that he had a passive death wish when sleep-deprived, but had no plan or intent. In June 2012, he noted a passive death wish one month prior, but denied suicidal ideation. In May 2013, he denied suicidal or homicidal ideation or passive death wish in the past year. He had suicidal ideation in August 2013, but no intent or plan. Homicidal ideation was denied at such time. The appellant experienced suicidal and homicidal ideation in September 2013, but had enough control to seek treatment and admission to a mental health facility due to such feelings. Such feelings resolved upon treatment. Suicidal and homicidal ideation was denied in October 2014. B.G. testified that she has witnessed suicidal ideation over the years, with the appellant expressing a desire to jump out of a window or car, and she has had to close the door or window and talk him down. The appellant also testified that he wanted to become violent toward his bosses, but left the job rather than give in to those feelings. The Board finds that all of such more nearly approximates the 70 percent criteria of suicidal ideation and impaired impulse control, such as unprovoked irritability with periods of violence, rather than a persistent danger of hurting self or others, which is contemplated by the 100 percent criteria. The evidence establishes that the appellant requires assistance with the performance of activities of daily living. However, some of this arises from his service-connected left knee degenerative joint disease and his nonservice-connected rheumatoid arthritis and other lower extremity problems. Indeed, in November 2012 statements, D.G. and the appellant's daughter reported that the appellant needed assistance with activities of daily living due to his rheumatoid arthritis and foot and knee problems. The August 2010 examiner noted that the appellant's ability to perform activities of daily living was not affected by his PTSD. Further, the above evidence reflects that the appellant maintains social contact, including with his siblings, his children, B.G., and a fellow veteran who lives in his building. No examiner opined that that the appellant experienced total occupational and social impairment, the two elements required for a 100 percent schedular rating. Rather, the October 2011 VA examiner opined that the appellant's PTSD caused occupational and social impairment with reduced reliability and productivity. The February 2017 contracted examiner opined that the appellant experienced occupational and social impairment with deficiencies in most areas. The Board finds that the October 2011 and February 2017 opinions are entitled to great probative weight because they are based upon thorough examinations of the appellant. The February 2017 examiner also reviewed the claims file, which entitles such opinion to even greater probative weight. Thus, the evidence does not more nearly approximate total occupational and social impairment. The Board also observes that the evidence does not establish that Dr. V.H.P. believed that the appellant experienced total social and occupational impairment. Rather, Dr. V.H.P. opined in October 2013 that the appellant experienced occupational and social impairment with both reduced reliability and productivity, and also with deficiencies in most areas. Thus, entitlement to a schedular rating of 70 percent for PTSD, but no higher, is warranted. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. V. Entitlement to TDIU The Board observes that the appellant did not file a timely substantive appeal with respect to the issue of entitlement to TDIU following the June 2014 SOC. In any event, the Board has considered entitlement to TDIU based upon his service-connected PTSD, pursuant to Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). As the appellant has been granted a 70 percent rating for PTSD, he meets the schedular criteria for consideration of TDIU. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a). Upon weighing the evidence, however, the Board finds that the preponderance of the evidence is against the appellant being unemployable due to his service-connected PTSD. The August 2010 examiner opined that the appellant's employability was fair and that he was not unemployable. At the time of such examination, the appellant was not working, but this was not due to his PTSD. In October 2011, the appellant reported that he worked as a construction contractor and that his supervisor affords him flexibility due to his physical pain. Work was consistent because he tries to be a "people person." He also held a part-time paid sedentary position pulling records. The October 2011 VA examiner opined that the appellant experienced difficulty in establishing and maintaining effective work relationships, but did not opine that the appellant was unemployable. In May 2013, the appellant retired because he did not feel comfortable performing physical labor on a construction site. In October 2013, Dr. C.J. opined that the appellant was unemployable due to his service-connected disabilities because he had impairment of the mind or body from his service-connected PTSD which rendered it impossible for the average person to follow a substantially gainful occupation. Dr. C.J. explained that the appellant was unable to work due to the severity of his PTSD symptoms and depression. He had difficulty with anger, mood problems, sleep problems, and an inability to be around people. In October 2013, Dr. V.H.P. opined that the appellant experienced occupational and social impairment with reduced reliability and productivity, and occupational and social impairment with deficiencies in most areas. The most prevalent symptoms included nocturnal panic attacks, anxiety, disturbance of mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. Dr. V.H.P. opined that the appellant was unemployed due to his service-connected PTSD. In a statement dated December 2012 but received in December 2013, the appellant stated that he misses more time from work than he actually works during the week. His employer has accommodated him by reassigning him to a primarily sedentary position. However, he is still unable to be productive. A home healthcare provider from VA must come to his home on occasion to assist with daily activities of living including bathing, washing clothing, and eating. He also receives help from family and friends due to difficulties standing or walking for long periods. His income was not sufficient due to his inability to work consistently. He contended that he is unable to secure or follow any substantially gainful occupation due to his service-connected disabilities. A December 2012 earning statement indicated that he used 665 hours of leave without pay and 480 hours of family leave in 2012. On his December 2013 Form 21-8940, the appellant contended that his rheumatoid arthritis and total knee replacement prevented him from securing or following any substantially gainful occupation. However, he did not contend that his PTSD contributed to such unemployability. November 2012 statements from D.G. and the appellant's daughter indicate that they believed that the appellant's rheumatoid arthritis and other lower extremity problems precluded him from being able to move around or work regularly. PTSD symptoms were not noted. During his February 2017 examination, the appellant endorsed suspiciousness with supervisors and "problems with authority." He stated that he attempted to work in a compensated work therapy (CWT) program, but "people were trying to stop [him] from working." He works part-time for pay, but has been "written up" for "petty things" and is unsure how much longer the job will last. He hopes to work more when his leg has healed but is not optimistic due to health problems. The examiner opined that the appellant experienced difficulty in establishing and maintaining effective work and social relationships, but did not opine that the appellant was unable to work due to his PTSD. The Board observes that the Social Security Administration (SSA) informed VA in January 2010 that there were no medical records on file for the appellant. A March 2010 Formal Finding on the Unavailability of SSA records confirms such and describes the steps taken by VA to obtain any SSA records per the appellant's July 2009 request. Although the appellant has competently reported problems with bosses at work due to paranoia, problems with authority, anger, and quitting a job in lieu of becoming violent, the most probative evidence establishes that his PTSD alone does not preclude him from securing or following a substantially gainful occupation. Although a December 2012 earning statement indicates that he used 665 hours of leave without pay and 480 hours of family leave, it is not contended that all or most of such was due solely to his PTSD symptomatology. In December 2013, the appellant believed that he was unemployable due to rheumatoid arthritis and a total knee replacement, but not because of his PTSD. In February 2017, the appellant reported that he was working part-time but was unsure how long such position would last. He indicated that he hoped to work when his leg healed, but was not optimistic due to generalized health problems. Thus, it appears that the appellant himself believed that his PTSD was not precluding him from working more; rather, it was other health problems. During his June 2017 hearing, he explained that he quit a job two years prior because he could not find a place to vent when he experienced a desire to hurt his boss after being picked on. He also reported that he retired earlier than he wanted to due to multiple leg operations and that a doctor recommended he not return to work. The Board has considered the medical opinions referenced above regarding the effect of the Veteran's PTSD on his employability. The Board is cognizant that "applicable regulations place responsibility for the ultimate TDIU determination on the [adjudicator], not a medical examiner." Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). However, the Board has considered the February 2017 VA examiner's opinion that the appellant only experiences difficulty in establishing and maintaining effective work relationships and finds that it is entitled to great probative weight as it is well-reasoned and based upon an examination of the appellant and a review of the claims file. It is consistent with the evidence of record. The Board affords this opinion greater probative weight than the October 2013 opinions from Dr. C.J. and Dr. V.H.P. because (1) Dr. C.J. only reviewed private hospital and treatment records, while the record indicates that the appellant received a great deal of treatment from VA facilities; and (2) there is no indication that Dr. V.H.P. reviewed any medical records in conjunction with offering the opinion. Further, the October 2011 examiner came to the same conclusion as the February 2017 examiner, although it is not noted whether the October 2011 examiner reviewed the claims file or simply based the opinion upon an examination of the appellant. The question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether the veteran is actually employed or can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In this case, the most probative evidence establishes that the appellant is not unable to secure or follow a substantially gainful occupation as a result of his service-connected PTSD. Although his service-connected PTSD quite clearly impairs his ability to interact with others, the record reflects that he is capable of performing work with minimal interaction with others. Further, to his credit, he has been able to extricate himself from stressful work situations before he would become violent. In October 2011, he stated that he gets work because he tries to be a "people person." While the Board recognizes the limitations the appellant faces due to his service-connected PTSD, these limitations were considered in the disability ratings he receives for those disabilities. Again, the assignment of the schedular rating is recognition of the functional limitations caused by his disabilities, and such rating contemplates the severity and overall impact the symptoms of PTSD have on his life. However, despite these limitations, the Board finds that the most probative evidence shows that the appellant is not unable to secure or maintain substantially gainful employment due solely to his service-connected PTSD. Rather, the Board finds that the appellant was capable of performing the physical and mental acts required for employment. As the evidence preponderates 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 v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to a rating of 70 percent, and no higher, for posttraumatic stress disorder (PTSD) is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a total rating based on individual unemployability due to service-connected disability is denied. ______________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs