Citation Nr: 20021357 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 12-31 965 DATE: March 25, 2020 ORDER 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to April 29, 2015 is denied. 2. Entitlement to an initial rating in excess of 70 percent for PTSD from April 29, 2015 is denied. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. 4. Entitlement to an extraschedular rating in excess of 10 percent for a bilateral hearing loss disability prior to July 15, 2016, and 30 percent thereafter, is dismissed. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s PTSD symptomatology rose to the level of occupational and social impairment with deficiencies in most areas prior to April 29, 2015. 2. The preponderance of the evidence is against finding that the Veteran’s PTSD symptomatology rose to the level of total occupational and social impairment from April 29, 2015. 3. The preponderance of the evidence is against a finding that the Veteran is unable to obtain and maintain any form of substantially gainful employment due to his service-connected disabilities. 4. On December 23, 2019, the Veteran, through his representative, submitted a written statement that explicitly and unambiguously expressed an intent to withdraw the appeal in connection to the claims for an extraschedular rating in excess of 10 percent for a bilateral hearing loss disability prior to July 15, 2016 and a 30 percent rating thereafter. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 50 percent PTSD prior to April 29, 2015 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1–4.10, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to an initial rating in excess of 70 percent for PTSD from April 29, 2015 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1–4.10, 4.130, Diagnostic Code 9411. 3. The criteria for entitlement to a TDIU rating have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 4. The criteria for withdrawal by the Veteran for the issue of entitlement to an extraschedular rating for a bilateral hearing loss disability at a rate of 10 percent prior to July 15, 2016 and a 30 percent rate thereafter have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has recognized Philippine Guerilla Service from December 1944 to April 1945. The Veteran testified at a videoconference hearing with a Decision Review Officer (DRO) in October 2013, at which the Veteran and his granddaughter testified. A transcript of the hearing was prepared and associated with the claims file. In a September 2014 decision, the Board granted an initial rating of 50 percent for PTSD, but denied a rating in excess of 50 percent. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). In an April 2015 Order, the Court granted a Joint Motion for Remand (JMR) and remanded the issue of entitlement to an initial rating in excess of 50 percent for PTSD to the Board for action consistent with the JMR. In May 2015, the RO increased the Veteran’s rating for PTSD to 70 percent from April 29, 2015. In the September 2014 Board decision, the Board also remanded the issues of entitlement to an increased rating for a bilateral hearing loss disability and entitlement to a TDIU rating for additional development. There was no indication the development had been completed. Therefore, in July 2015, the Board again remanded these issues as well as the issue of entitlement to an initial rating in excess of 50 percent for PTSD prior to April 29, 2015 and an initial rating in excess of 70 percent for PTSD from April 29, 2015. A May 2017 rating decision granted a 30 percent rating for a bilateral hearing loss disability from July 15, 2016, and in an October 2017 decision, the Board denied the Veteran’s claims for higher ratings. The Veteran appealed the Board’s October 2017 decision to the Court. In a July 2018 Order, the Court granted a JMR and remanded the issues of entitlement to an initial rating in excess of 50 percent prior to April 29, 2015 and an initial rating in excess of 70 percent from April 29, 2015 for PTSD, entitlement to an extraschedular rating for bilateral hearing loss in excess of 10 percent prior to July 15, 2016 and 30 percent thereafter, and entitlement to a TDIU rating to the Board for action consistent with the JMR. In January 2019, the Board issued a decision denying the Veteran’s claims remanded to the Board following the Court’s July 2018 Order granting the JMR. After the issuance of the Board’s January 2019 decision, the Veteran’s Form 21-22a, which changed the Veteran’s representative from AMVETS to Joseph R. Moore, was scanned into VBMS. Thus, in March 2019, the Board vacated the January 2019 Board decision to provide the Veteran’s newly appointed attorney sufficient time to submit evidence and argument on the Veteran’s behalf. The Veteran has since submitted additional private treatment records, a private VA examination, and argument. Increased Rating 1. – 2. Entitlement to an initial rating in excess of 50 percent for PTSD prior to April 29, 2015 and 70 percent thereafter Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of the disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provide the following ratings for psychiatric disabilities, including PTSD: A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the formula, a 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations, grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The United States Court of Appeals for the Federal Circuit held that 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.” Vasquez-Claudio v. Shinseki, 713 F3d 112, 116–17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather, “serve as examples of the type and degree of symptom, 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.’” Vasquez-Claudio, 713 F.3d at 117–18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, 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.” 38 C.F.R. § 4.126(a). The Board 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 examination.” Id. The Global Assessment of Functioning (GAF) scale is a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.” Diagnostic and Statistical Manual of Mental Health Disorders (4th ed. 1994) (DSM-IV). A GAF score of 41 to 50 reflects 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). DSM-IV; 38 C.F.R. §§ 4.125, 4.130. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, 8 Vet. App. at 242. An assigned GAF score, like an examiner’s assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). Accordingly, an examiner’s classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VACOPGREC 10-95, 60 Fed. Reg. 43186 (1995). The DSM-5 no longer utilizes GAF scores, and as such, after August 2014, GAF scores are no longer used by VA to assign a psychiatric rating. However, as the Veteran filed his claim prior to August 2014, the Board will consider the assignment of GAF scores to the extent they are available in the record prior to this date. (a) Prior to April 29, 2015 The Veteran was first diagnosed with PTSD in October 2010. At the Veteran’s initial VA mental health assessment, conducted in November 2010, the Veteran reported the following symptoms: intrusive thoughts, nightmares, flashbacks, physical reactions to reminders of trauma, avoidance behaviors, difficulty remembering important aspects of trauma, loss of interest in significant activities, difficulty sleeping, difficulty concentrating, irritability and anger, guardedness, an exaggerated startle response, feelings of emptiness and depression, boredom, dysphoria, isolating behaviors, and a lack of energy. The Veteran also endorsed feeling helpless, worthless, and hopeless. The Veteran reported that he retired from his position as a security guard in 2008 and spent most of his leisure time watching television. The Veteran also reported that he had a “very good” relationship with his family, and he had been happily married to his wife since 1947. The VA psychologist noted that the Veteran was cooperative, his speech was within normal limits, his thought processes were linear, his grooming was appropriate, and his insight and judgement were fair. The Veteran did not endorse delusions or homicidal or suicidal ideation. The VA psychologist did note that the Veteran’s mood was depressed and his affect was appropriate to his mood, but the Veteran was alert and fully oriented. The Veteran was diagnosed with PTSD and major depressive disorder, and the examiner assigned a GAF score of 45. The Veteran was provided a VA psychiatric examination in March 2011. The Veteran reported the following symptoms: nightmares, daydreams of traumatic events, difficulty sleeping, recurrent and intrusive distressing recollections and dreams, intense psychological distress and physiological reactivity upon exposure to internal or external cues, a sense of a foreshortened future, avoidance behaviors, diminished interest in significant activities, suspiciousness, hypervigilance, and some visual hallucinations, though they were not persistent. The Veteran reported irritability and outbursts of anger, but he also reported that he had learned how to control himself during these outbursts. The Veteran noted that he had a few friends, though not many, and still enjoyed some significant activities; including watching television, playing ping pong, and going to the movies. He also noted that he had recently celebrated his 60th wedding anniversary with his wife, and he maintained a good relationship with his wife, his daughter, and his grandchildren. The VA examiner noted that the Veteran was neatly groomed and appropriately dressed, cooperative, friendly, attentive, polite, alert, and fully oriented. The examiner noted that the Veteran’s mood was anxious and he appeared intense, but his affect was appropriate, though restricted. The Veteran’s speech, thought processes, and thought content were reported to be unremarkable. The examiner also noted that the Veteran’s intelligence was above average, he understood the outcomes of his behavior and that he had a problem, his behavior was appropriate, and his memory was normal. The Veteran did not endorse delusions, obsessive or ritualistic behaviors, panic attacks, or homicidal or suicidal ideation. The examiner assigned a GAF score of 50. From May 2011 to October 2011, the Veteran was seen on a regular basis at VA for treatment of his PTSD. Additionally, the Board notes that the Veteran went to VA for some treatment before and after this time period on an irregular basis. During this time, the Veteran reported that he participated at his church and maintained a good relationship with his wife and family. The Veteran reported the following symptoms: depression, emotional numbness, feelings of nervousness and apprehension when recalling traumatic experiences, avoidance behaviors, difficulty sleeping with persistent insomnia, loss of interest in significant activities, isolation behaviors, anger and irritability, and recurrent intrusive thoughts, memories, and nightmares, occasionally waking up startled and disoriented. The Veteran denied feelings of hopelessness and worthlessness, psychotic symptoms, obsessive rituals, panic attacks, difficulty with motivation, and homicidal and suicidal ideation. Treatment providers during this time noted that the Veteran’s symptoms appeared to be improving, and he was gaining the ability to better manage his symptoms. The Veteran was also consistently noted to be pleasant, cooperative, polite, and alert and fully oriented with normal speech, fair insight and judgment, and logical thought processes. The Veteran attended group therapy from November 2011 to February 2012. It was consistently noted that the Veteran was well-groomed and exhibited appropriate behavior at group meetings. In October 2013, the Veteran testified at a hearing, presided over by a DRO. The Veteran’s granddaughter attending the hearing to assist in translation and provided some testimony as well. The Veteran testified at the hearing that he had the following symptoms: flashbacks, nightmares, feelings of sadness, and difficulty sleeping—reporting that he only got approximately three hours of sleep at a time before waking up. The Veteran’s granddaughter testified that the Veteran sometimes woke up looking startled or as though he was having a seizure, noting that he would sometimes shout as though he was afraid of some unknown threat. The Veteran’s granddaughter also noted that the Veteran exhibited behaviors of hypervigilance, such as frequently locking doors and windows. The Veteran testified that he preferred to stay home but that he does have some friends, occasionally invited neighbors over, and took trips with friends and had recently returned from a trip to Las Vegas. He also noted that he had a relationship with his brothers. The Veteran testified that he sometimes does not want to get out of bed and felt tired with life. The granddaughter testified that the Veteran had told her that he did not want to live anymore. The Veteran was provided another VA examination in March 2014. The Veteran endorsed the following symptoms: recurrent involuntary and intrusive distressing memories and dreams, intense or prolonged psychological distress and physiological reactions to internal or external cues, avoidance behaviors, persistent and exaggerated negative beliefs, persistent negative emotional state, diminished interest in significant activities, feelings of detachment or estrangement from others, irritable behavior and angry outburst, exaggerated startle response, difficulty concentrating, sleep disturbances and difficulty sleeping, and anxiety. The VA examiner diagnosed the Veteran with PTSD and noted that he was able to manage his finances. In October 2014, VA treatment records document that the Veteran expressed suicidal ideation with no intent or plan. The Veteran further reported that he knew it was not a good idea to kill himself because he needed to care for his family. The Veteran specifically denied active suicidal ideation several times and denied a history of suicidal ideation. The examiner noted that the Veteran was a low risk of self-harm, and that he was fully oriented with normal speech and thought processes and appropriate grooming. The Veteran appeared depressed and tearful at this appointment, but his insight and judgment were noted to be fair with no evidence of psychotic processes. The Board also acknowledges the private examination, conducted in December 2019, that retrospectively comments on the Veteran’s symptomatology. After a review of the file and an interview with the Veteran and the Veteran’s granddaughter, Dr. Michael Cesta opines that the Veteran has been totally disabled by his PTSD since at least 2008. Even acknowledging the Veteran’s major vascular neurocognitive disorder, the examiner opined that the Veteran’s significant PTSD symptoms predated this diagnosis. The Veteran’s granddaughter and the Veteran both endorsed that the Veteran had significant symptoms prior to his neurocognitive diagnosis. The examiner then went on to note that the Veteran experienced the following symptoms, likely with an onset prior to 2008: severe social isolation, profoundly impaired interpersonal relationships, dissociative episodes, intrusive memories, exaggerated startle response, recklessness, negative thinking, difficulty experiencing positive emotions, frequent flashbacks, nightmares insomnia, loss of focus, difficulty concentrating, anger, and volatile outbursts. The examiner opined that these symptoms were severe and worsening over time since the Veteran’s active service. Following a thorough review of the evidence of record, the Board finds the symptomatology during this part of the appeal period more closely approximates occupational and social impairment with reduce reliability and productivity rather than occupational and social impairment with deficiencies in most areas, which is required for the higher 70 percent rating. The reasons for this determination follow. In the March 2014 VA examination report, when asked which of the following best summarized the Veteran’s level of occupational and social impairment, the psychologist checked occupational and social impairment with occasional decrease in work efficiency, which is the level of severity described under the 30 percent rating. While the adjudicator makes the determination of what evaluation is warranted for the service-connected PTSD, the examiner’s conclusion that the Veteran’s PTSD was summarized best by the criteria described under the 30 percent rating is evidence against a finding that the Veteran’s psychiatric disorder caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood to warrant a 70 percent rating or higher. During the period on appeal, the Veteran consistently reported a good relationship with his immediate family, including his wife, child, and grandchildren. The Veteran also endorsed that he had a few friends, though not many, and that he reported that he would invite his neighbors over to his house. He even reported he was able to take a trip to Las Vegas. The Board acknowledges that he quit his job in 2008 and had not sought other employment, but the Veteran does not assert that he stopped working because of his PTSD symptoms. This is supported by the Veteran’s VA Form 21-8940, submitted in June 2016, wherein the Veteran reported that he had become too disabled to work from PTSD and other disabilities in November 2012, which was after the Veteran retired. Additionally, the Veteran did not report that his PTSD was the sole basis for his inability to obtain and retain gainful employment beginning in November 2012, but rather, the Veteran reported that his unemployability was due to multiple disabilities (some of which are not service connected and will be discussed more in detail below). The Board finds the aforementioned to be evidence that the Veteran’s social and familial relationships were, at worst, impaired such that they caused reduced reliability prior to April 29, 2015. Given that he has maintained relationships with friends, family, and neighbors and was able to travel, be in crowded, public spaces such as Las Vegas, and continued to go to church, this is evidence against deficiencies in family relations and against the inability to establish and maintain effective relationships. The Board finds the Veteran’s symptoms do not rise to the level impairment indicative of social and occupational impairment with deficiencies in most areas. While the Veteran was frequently noted to have a depressed or anxious mood, his insight and judgment, thought processes, and speech were consistently found to be normal. His grooming was appropriate, and he was cooperative, polite, alert, and fully oriented. The Veteran did not display evidence of psychosis, obsessive rituals, panic attacks, hallucinations, or homicidal ideation. Though the Veteran did report visual hallucinations on one occasion, his reporting on this symptom did not continue and at the time he noted the visual hallucinations, he also noted that they were not persistent. The Veteran’s grooming was consistently noted to be appropriate, and VA examiners noted he was able to manage his finances. Additionally, the Veteran was noted to have above-average intelligence, and the Veteran’s claims file does not show he had significant difficulty with memory or concentration. The Veteran did exhibit some irritability and outbursts of anger, often noting that his anger and irritability were unprovoked. However, during this time period, the Veteran consistently noted that he was able to recognize these symptoms and had been able to manage them, especially when taking medication. The Board finds these symptoms are consistent with the rating criteria described by a 50 percent rating, and the preponderance of the evidence is against a finding that the Veteran exhibited symptoms of obsessional rituals interfering with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression impacting the ability to function independently, appropriately, and effectively; spatial disorientation; and neglect of personal appearance and hygiene, or symptoms similar to these symptoms, which are described as symptoms of occupational and social impairment with deficiencies in most areas indicative of a 70 percent rating. The Veteran’s GAF scores of 45 and 50 assigned during the appeals period also do not support a higher rating. Though scores of 45 and 50 reflect serious symptoms, the symptoms do not rise to the level of impairment in reality or communication. Moreover, the Board notes that the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual for Mental Disorders, 5th edition (DSM-5), effective for VA rating purposes as of August 2014, does not utilize the GAF scores. The APA determined that the GAF score had limited usefulness in the assessment of the level of mental health disability, and therefore, it was removed from the DSM-5; noting that problems included a lack of conceptual clarity and doubtful value of GAF psychometrics in clinical practice. See 79 Fed. Reg. 45,093, 45,097 (Aug. 4, 2014). The Board acknowledges the Veteran’s treatment records and VA examinations that document that the Veteran expressed passive suicidal ideation during this time period, beginning at the October 2013 DRO hearing. However, the facts of this case are distinguishable from those described in Bankhead v. Shulkin, 29 Vet. App. 10 (2017), in which the Court held that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas (a 70 percent disability rating under 38 C.F.R. § 4.130). Under the facts of Bankhead, the claimant was noted to have had recurrent suicidal thoughts and behaviors of varying severity, frequency, and duration throughout the relevant appeal period. Here, the Veteran’s reports of passive suicidal ideation do not cause the level of occupational and social impairment contemplated by the 70 percent disability rating as the evidence also suggests that the Veteran had not reported a plan or intent to carry out his suicidal ideation, and though he did note that he feels tired of his life and expressed feeling of hopelessness and helplessness, VA examiners have noted that the Veteran presents a low risk of self-harm. The Veteran’s overall disability picture does not rise to the level of deficiencies in most areas during this part of the appeal period. The Board also acknowledges the December 2019 private examination submitted by the Veteran. However, the Board finds this examination is less probative as it reports symptomatology that is inconsistent with the concurrent medical treatment records, which document symptoms contemporaneously with the time period in question. The Board finds the concurrent medical records to be more probative of the Veteran’s symptomatology at that time than the Veteran’s statements made approximately 10 years later. While the Board acknowledges that the Veteran had significant symptoms of PTSD prior to the Veteran’s diagnosis of a neurocognitive disorder and since his discharge from service, that does not mean that the Veteran’s symptoms warrant a rating of 70 or 100 percent. Therefore, the Board finds that the Veteran’s PTSD symptoms are most closely approximated by the assigned 50 percent disability rating. Importantly, as described in detail above, the preponderance of the evidence is against the Veteran showing occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood; nor are his PTSD symptoms of similar severity, frequency, and duration to warrant an increased 70 percent disability rating. As the Board has found that the Veteran's disability picture does not rise to the level of severity of the 70 percent rating, it follows that the Board finds that the disability picture does not rise to the level of severity of the 100 percent rating. Considering the Veteran’s total disability picture, as noted in detail above, the Board finds the preponderance of the evidence is against an initial evaluation in excess of 50 percent prior to April 29, 2015. Therefore, a rating in excess of 50 percent prior to April 91, 2015 for PTSD is denied. (b) From April 29, 2015 In April 2015, the Veteran was provided a VA examination. At this examination, the Veteran was diagnosed with PTSD and vascular dementia. The examiner noted that the Veteran suffered a stroke in 2012, and since that time, the Veteran had had noticeable cognitive decline. Therefore, the examiner opined that the Veteran’s cognitive decline was more likely than not related to the Veteran’s stroke and was not likely related to the Veteran’s PTSD. As such, the Veteran’s reported symptoms such as difficulty establishing and maintaining work and social relationships, difficulty understanding complex commands, impaired judgment and impulse control, intermittent inability to perform activities of daily living, and impairment of long and short-term memory were more than likely associated with the Veteran’s vascular dementia and stroke rather than his PTSD. Despite this, the examiner noted that approximately 10 percent of the Veteran’s occupational and social impairment was associated with the Veteran’s PTSD diagnosis. The Veteran, and his granddaughter, who was also at the examination, reported PTSD symptoms including: recurrent involuntary and intrusive distressing memories and dreams of traumatic events, avoidance behaviors, irritability, persistent and exaggerated negative beliefs or expectations, sleep disturbance, and depressed mood. The Veteran’s granddaughter also noted that the Veteran would still wake up in the middle of the night, sometimes screaming. At the time of the examination, the Veteran was still married, and his grandchildren assisted with his daily care. The Veteran reported that he was still able to go out to restaurants. The Veteran also did not endorse homicidal or suicidal ideation. The examiner wrote that the Veteran was difficult to understand at this examination but noted that this was due to a language barrier and because the Veteran had lost teeth rather than his inability to understand or communicate. In August 2015, the Veteran was found to be incompetent, as he was unable to manage his financial affairs. A January 2017 letter from a VA physician who had treated the Veteran opined that the Veteran did not suffer from dementia and was able to manage his finances. However, there was no rationale for this opinion, and the physician did not report any symptomatology to support that opinion. In a July 2017 rating decision, the Veteran was found to be competent. Since the Board vacated its January 2019 decision, the Veteran submitted additional VA treatment records. However, these records do not document ongoing treatment for the Veteran’s mental health. Rather, they document that depression screens conducted in July 2016, August 2017, and October 2018 were negative. Additionally, October 2018 records document that the Veteran’s suicide screen was zero, suggesting he presented with a low risk of self-harm, and a PTSD screen score was also zero. In December 2019, the Veteran submitted a private examination conducted by Dr. Michael Cesta, briefly noted above. This evaluation was based on a review of the evidence in the file and an interview with the Veteran in November 2019 with the assistance of the Veteran’s granddaughter. As noted above, Dr. Cesta noted significant PTSD symptomatology that the Veteran was experiencing at the time of the interview, which he also reported the Veteran had been experiencing since prior to 2008. Additionally, at this examination the Veteran’s granddaughter reported that interactions with the Veteran’s family had gotten worse as his PTSD had worsened, which she noted had caused disarray in the family. The Veteran expressed shame and guilt about his behaviors, a history of anger and emotional outbursts, and that he was personally damaged by his PTSD. Dr. Cesta conducted a formal mental status exam, noting that the Veteran was cooperative and appropriate during the interview with no evidence of agitation or impulsivity, despite flattened and garbled speech and a mood described as “not good.” Dr. Cesta noted that the Veteran’s affect was constricted and in the dysphoric range with underlying anger, but he did not express homicidal or suicidal ideation, though he noted he had contemplated suicide in the past. Dr. Cesta documented that there were no delusions or perceptual alterations, though it was noted that the Veteran endorsed dissociative episodes. Dr. Cesta also documented that he was not cognitively intact and was too disorganized to perform formal testing. Following a thorough review of the relevant evidence of record, the Board finds the aforementioned symptomatology more closely approximates occupational and social impairment with deficiencies in most areas rather than total occupational and social impairment, which is required for the higher 100 percent rating. As noted by the April 2015 VA examiner, the Veteran is totally occupationally and socially impaired. However, the examiner also opined that approximately 90 percent of this impairment is related to the cognitive decline associated with the Veteran’s 2012 stroke and vascular dementia, and not the Veteran’s PTSD symptoms. While the Veteran is not so cognitively impaired that he cannot manage his finances, the Board finds the opinion of the April 2015 VA examiner noting that the Veteran has significant cognitive impairment associated with his stroke to be more probative than the January 2017 letter from a VA physician, as the April 2015 VA examiner provided a more thorough rationale in reporting the symptomatology used to provide the opinion that the Veteran was cognitively impaired following his 2012 stroke. The Board also finds that this opinion is more probative than the opinion provided by Dr. Cesta in his December 2019 private opinion. While Dr. Cesta did note that the Veteran had a neurological disorder, he opined that the Veteran had PTSD symptoms that pre-dated the neurocognitive disorder. The Board does not dispute that the Veteran had significant PTSD symptoms prior to developing his neurocognitive disorder, which is also acknowledged by the April 2015 examiner; however, significant symptomatology does not mean that those symptoms rise to the high bar of total occupational and total social impairment. The Veteran’s remaining symptoms related solely to his PTSD do not cause total occupational and social impairment. The Veteran has remained married and sustains relationships with his family. This is evidence against total social impairment. He is also still able to go to restaurants with assistance. The Veteran still exhibits avoidance behaviors, depression, difficulty sleeping, irritability, and significant symptoms associated with the trauma he experienced during his active duty, but he does not exhibit current symptoms of hallucinations, delusions, and grossly inappropriate behavior. The Veteran’s past reports of visual hallucinations were not persistent. Furthermore, at the April 2015 VA examination, the Veteran no longer endorsed suicidal ideation, and did not exhibit any desire to harm others, consistent with later VA treatment records from 2016 to 2018. The Board finds these are all indicative of symptomatology against a finding that the Veteran was totally socially and occupationally impaired due to PTSD symptoms. Additionally, the Board finds it probative that the December 2019 private examiner noted that the Veteran was able to express a history of shame and guilt about his behaviors as well as his history of emotional outbursts. The Board, again, acknowledges the opinion provided by Dr. Cesta in December 2019. However, despite the examiner’s opinion that the Veteran is unable to work due to his significant PTSD symptoms, the symptomatology described by Dr. Cesta does not rise to the level of total social impairment. The examiner documented that, though impaired, the Veteran was cooperative and appropriate, did not exhibit agitation or impulsivity, and displayed no evidence of homicidal or suicidal ideation or evidence of delusions or perceptual alterations. The Board finds these reports are indicative of at least some ability to engage occupationally and socially, and thus, the symptoms do not rise to the level of total occupational and total social impairment for entitlement to a 100 percent rating. To reiterate, the Veteran still has relationships with his family, which is affirmative evidence against a finding of total social impairment. For the 100 percent rating, there must be both total occupational and total social impairment, which the Veteran does not have. Therefore, the Board finds that the Veteran’s PTSD symptoms are most closely approximated by the assigned 70 percent disability rating, which contemplate deficiencies in most areas. Importantly, as described in detail above, the preponderance of the evidence is against the Veteran showing total occupational and social impairment due solely to his PTSD symptoms; nor are his PTSD symptoms of similar severity, frequency, and duration to warrant an increased 100 percent disability rating. Considering the Veteran’s total disability picture, as noted in detail above, the Board finds the preponderance of the evidence is against an initial evaluation in excess of 70 percent from April 29, 2015. Therefore, a rating in excess of 70 percent from April 29, 2015 for PTSD is denied. TDIU 3. Entitlement to a TDIU rating A TDIU rating may be granted upon a showing that the veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 C.F.R. § 4.16(a). There are minimum disability rating percentages that must be shown for the service-connected disabilities, alone or in combination, to qualify for schedular consideration for a TDIU award under § 4.16(a). Indeed, if there is only one such disability, it must be rated at 60 percent or more; if instead there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. Id. If a veteran does not meet the aforementioned criteria, a total disability may still be assigned, but on a different basis. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Therefore, the rating boards are required to submit to the Director, Compensation Service, for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage of standards set forth in 38 C.F.R. § 4.16(a). Id. In determining whether a veteran is unemployable for VA purposes, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. A veteran need not show 100 percent unemployability in order to be entitled to a TDIU rating. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). The Court has held that the central inquiry in determining whether a veteran is entitled to a TDIU rating is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). The test of individual unemployability is whether a veteran, as a result of his or her service-connected disabilities alone, is unable to secure or follow any form of substantially gainful occupation which is consistent with his or her educational and occupational experience. 38 C.F.R. § 3.340, 3.341, 4.16. The Board also notes 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. 38 C.F.R. § 4.16(a); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran is service connected for PTSD at a 50 percent rate from November 30, 2010 and a 70 percent rate from April 29, 2015; a bilateral hearing loss disability at a 10 percent rate from November 30, 2010 and a 30 percent rate from July 15, 2016; and tinnitus of the right ear at a 10 percent rate from November 30, 2010. The Veteran’s combined rating for compensation is 60 percent from November 30, 2010 to April 28, 2015 and an 80 percent rate from April 29, 2015. The Veteran meets the schedular requirements for a TDIU rating from April 29, 2015. However, as noted above, the central inquiry in determining entitlement to a TDIU rating is whether the service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Additionally, as the Veteran does not have a combined total rating over 70 percent and no single disability rated at 60 percent prior to April 29, 2015, the schedular criteria for a TDIU rating have not been met prior to April 29, 2015. For this time period, the Board will consider whether referral for extraschedular consideration for a TDIU rating is warranted. For both periods on appeal, the Board finds that the preponderance of the evidence is against a finding that the Veteran was unable to maintain substantially gainful employment based on his service-connected disabilities alone at any point during the period on appeal. Following his discharge from service in April 1945, the Veteran obtained a Bachelor of Arts degree in political science. He taught high school part-time for two years and worked in government service and community development in the Republic of the Philippines for 25 years. The Veteran moved to the United States in 1992 and worked as a security guard. It is unclear from the record when the Veteran retired, as he has provided different dates. At the Veteran’s November 2010 mental health assessment and at his April 2015 VA psychiatric examination, the Veteran reported that he retired in 2008. However, March 2011 VA treatment records show that the Veteran retired in 2010, in part, because of his PTSD. At the Veteran’s March 2014 VA psychiatric examination and on his VA Form 21-8940, submitted in June 2016, the Veteran reported he quit his security job in 2009, that his disabilities affected full-time employment in August 2011, and that he became too disabled to work in November 2012. In the July 2018 VA Form 21-8940, the Veteran reported his disabilities affected full-time employment in 2010, that he last worked full time in 2010, and that he became too disabled to work in December 2010. In the June 2016 TDIU application, the Veteran included the following disabilities as precluding his ability to work: hip surgery (not service connected), PTSD (service connected), arthritis (not service connected), hard of hearing (service connected), and glaucoma (not service connected). In the July 2018 TDIU application, the Veteran included only PTSD and hearing loss as the disabilities precluding his ability to work. Notably, the Veteran is not service connected for arthritis, a hip disability, or glaucoma, and, as such, these disabilities cannot be considered in determining the Veteran’s entitlement to a TDIU rating. There are discrepancies between what the Veteran reported in the June 2016 TDIU application and what he reported in the July 2018 TDIU application. The Board finds that the facts documented in the June 2016 TDIU application to be more probative, as the Veteran provided detailed facts in that application, which lends reliability to them. Thus, these are the facts that the Board has relied upon as to when the Veteran last worked full time (2011), when he became too disabled to work (November 2012), and the income he earned working full time from 1993 to 2009, which was more than $30,000/year. As to the Veteran’s service-connected disabilities, the April 2016 VA examiner noted that the Veteran’s hearing loss and tinnitus would not likely impair the Veteran’s employability, opining that no amount of hearing loss would make a person totally occupationally impaired so long as visual cues, face-to-face communication, and amplification devices are implemented. The Veteran had been issued hearing aids by VA. Additionally, the Board finds the preponderance of the evidence is against a finding that the Veteran’s PTSD causes the Veteran to be unable to obtain or maintain employment. While the Board acknowledges that the Veteran’s PTSD symptoms impact the Veteran’s day-to-day life and has some impact on his employability, the Board finds the Veteran’s PTSD alone would not impact the Veteran’s ability to obtain and maintain substantially gainful employment. The April 2015 VA examiner opined that though the Veteran was totally socially and occupationally impaired, only approximately 10 percent of the Veteran’s impairment was the result of the Veteran’s service-connected PTSD. The remaining 90 percent of impairment, the examiner opined, was related to the Veteran’s nonservice-connected cognitive impairment associated with a stroke. As noted above, the Board finds this opinion to be the more probative medical opinion available in the claims file, which is evidence against a finding that the Veteran’s PTSD symptoms preclude substantially gainful employment. The Board has considered the opinions of the medical professionals; however, the ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator. The record shows that the Veteran has a college education in political science and worked in government service in the Philippines, in community development, and as a security guard. The Veteran is service connected for PTSD, hearing loss, and tinnitus. The June 2016 TDIU application shows that the Veteran worked in security from 1993 to 2009, after having taken security officer training in 1993, where he reported working 40 hours per week during that time period, which is 16 years of full-time work in that industry. As the Veteran has had experience in several industries and has a college education, the record supports that the Veteran could choose from professions that would not be impacted by the limitations of his service-connected disabilities. For example, the Veteran could work in security, an industry where he worked for 16 years on a full-time basis, perhaps working a night shift to avoid a lot of people contact due to his PTSD symptoms. Accordingly, the preponderance of the evidence is against a finding that the Veteran is precluded from all forms of substantially gainful employment due to the service-connected PTSD, hearing loss, and tinnitus. The standard for referral for extraschedular consideration is whether the Veteran is unable to obtain or maintain employment generally. As the preponderance of the evidence prior to April 29, 2015 is against a finding that the Veteran would be unable to obtain and maintain all forms of substantially gainful employment, despite his PTSD, hearing loss, and tinnitus, referral for extraschedular consideration is not warranted. Additionally, as the more probative evidence suggests that the Veteran’s service-connected disabilities do not prevent the Veteran from obtaining and maintaining substantially gainful employment, entitlement to a TDIU rating on a schedular basis from April 29, 2015 is also denied. Withdrawn Claim 4. Entitlement to an extraschedular rating in excess of 10 percent for a bilateral hearing loss disability prior to July 15, 2016 and 30 percent thereafter The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the veteran/appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, on December 23, 2019, the Veteran submitted a statement in writing, through his representative, indicating he wanted to withdraw his appeal as to his claim for extraschedular ratings for the service-connected bilateral hearing loss disability. Thus, the Veteran has withdrawn the appeal as it relates to this claim. Accordingly, the Board does not have jurisdiction to review the claim for entitlement to extraschecular ratings for the bilateral hearing loss disability, and it is dismissed. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Keninger, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.