Citation Nr: 20021852 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 10-04 104 DATE: March 27, 2020 ORDER 1. Entitlement to an initial disability rating in excess of 70 percent for major depressive disorder (MDD) with posttraumatic stress disorder (PTSD) is denied. 2. Entitlement to a total disability rating for compensation based upon individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran’s MDD with PTSD has not been manifested by total occupational and social impairment for any period on appeal. 2. The Veteran has not been precluded from securing or following a substantially gainful occupation due to her service-connected disabilities for any period on appeal. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 70 percent for MDD with PTSD have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code (DC) 9434 (2019). 2. The criteria for a TDIU rating have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 1978 to January 1986. The Veteran previously testified before the undersigned Veterans Law Judge (VLJ) at an August 2012 videoconference hearing and a transcript of the hearing has been associated with the claims file. To extent that the Veteran requested an additional hearing before the Board within an August 2018 VA Form 9 concerning her TDIU claim on appeal, she subsequently withdrew that request in September 2018 and reiterated her desire to withdraw the hearing request in July 2019. These matters were most recently remanded by the Board in January 2016. As the directed development has been completed, they are now properly returned to the Board for adjudication. 1. Entitlement to an initial disability rating for MDD with PTSD in excess of 70 percent. First, the Veteran asserts entitlement to an initial disability rating in excess of 70 percent for MDD with PTSD. Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. The Veteran’s service-connected MDD with PTSD is currently rated as 70 percent disabling from January 1, 2007 under Diagnostic Code (DC) 9434 of the General Rating Formula for Mental Disorders. Under the applicable rating criteria, a 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals, which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A maximum schedular 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact the veteran’s occupational and social impairment. The use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. 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). Scores ranging from 51 to 60 suggest moderate symptoms, or moderate difficulty in social, occupational, or school functioning. 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. 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). 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. Following a review of the evidence of record, and as discussed further below, the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to an initial disability rating in excess of 70 percent for MDD with PTSD for the entire period on appeal. VA treatment records from December 2006, just prior to the Veteran’s January 2007 claim, document her diagnoses of MDD in partial remission, social anxiety disorder, and a history of alcohol dependence. She reported that she felt uncomfortable and anxious in social situations since her mother died in 2003, but also noted that she had spent Christmas with her nephew and planned to set a weight loss goal for the new year, including participation in Weight Watchers or another support group. In February 2007, the Veteran reported that she started working at the Miami VA Medical Center (VAMC) in December 2001 and related feeling anxiety that almost led to her leaving the position after only three months, but that she spoke to a friend and was able to hold onto the job since that time, although she continued to suffer from social anxiety and received ongoing mental health treatment at Miami VAMC. In October 2007, her GAF score was noted to be 60. In January 2008, the Veteran was referred to the Vet Center for additional mental health treatment. In May 2008, her GAF score was noted to remain stable at 60. In November 2008, her physician recommended a leave of absence following her hysterectomy, as her psychiatric symptoms had exacerbated to increased stress at work. Her noted GAF score at the time had remained 60. In December 2008, she appeared alert and oriented, well-groomed, and pleasant, with good eye contact and organized thought processes. In January 2009, she reported anxiety attacks secondary to stress at her job and noted that she had not returned to work following hysterectomy surgery. She was feeling anxious about having to start work again the following week, and her assigned GAF score remained 60. In March 2009, she was enrolled in PTSD clinical team weekly group therapy. Throughout April 2009, her noted GAF score remained 60. In May 2009, the Veteran reported being upset about a dispute with her supervisor where she felt harassed and treated unfairly. She reported she was currently looking for another job and stated that she would like to stay with the federal government. Her therapist encouraged her to continuously seek active employment in a service where she may feel rewarded and happy. In July 2009, she continued to attend weekly group therapy, and it was noted that she would also benefit from weekly stress management. That same month, she reported feeling overwhelmed secondary to difficulties within her work environment. She noted symptoms of low energy and hopelessness about work, but she denied suicidal or homicidal ideation. Her assigned GAF score was lowered to 42. Upon mental status examination just days later, she appeared alert and oriented, maintained eye contact, and was cooperative and pleasant, with normal speech and thought processes. She denied suicidal or homicidal ideation, and auditory or visual hallucinations, but reported feeling guarded, stressed, and anxious around the workplace and in the presence of her supervisors. Her GAF score was raised slightly to 44. Later, in July 2010, she was noted to be stable upon psychiatric follow up. Within a June 2011 lay statement, the Veteran’s sister reported that the Veteran had problems at work due to fear of working around so many people and sensitivity to criticism. She reported that the Veteran lived alone and did not have many friends or acquaintances, although she continued to attend therapy and wanted to find a partner in life. She reported that their relationship had started to deteriorate, especially after their mother passed away in 2003, and that the Veteran did not attend family reunions, birthdays, or holidays to avoid being around so many people. VA treatment records from March 2012 document that the Veteran remained stable and she continued to deny suicidal or homicidal ideation. In May 2012 and July 2012, her documented GAF score remained 50. In August 2012, she again denied homicidal or suicidal ideation. Within an August 2012 buddy statement, a coworker of the Veteran reported that they had worked together for almost three years and she considered the Veteran as one of her closest friends. She reported that the Veteran was a hard worker, but noted she always had some type of conflict with someone at work. She reported that about a year and a half ago, the Veteran was having a lot of problems with her supervisor, and after several meetings the final outcome was to switch her to a different department. Additionally, the coworker reported that she had asked, and the Veteran had offered, to be the photographer at her wedding, but that the Veteran was unsure if she would be up for it due to her psychiatric symptoms. She stated that the Veteran was a good person, but that she was not emotionally stable and unable to keep plans, even when invited by her coworker friend to various volunteer events or church functions. That same month, the Veteran’s private psychologist reported in a letter that the Veteran’s numerous psychological problems had contributed to chronic unhappiness, loneliness, and feelings of alienation. The psychologist stated that her vocational life, family relations, and social life had been fraught with instability and conflict, including a series of unhealthy relationships with men who were verbally and/or physically abusive. More recently, in the past 10 years or so, she has been fairly socially isolated with few friends, and that she avoids meeting new people and often becomes depressed on holidays, vacations, and weekends. Over the years, the Veteran has had numerous jobs in a variety of clerical and office work capacities, though she has left most due to problems with supervisors and bosses, which problems have usually been precipitated by her extreme sensitivity and paranoid thinking. She easily feels slighted, abused, or taken advantage of, and reaches a point where she feels too anxious to continue her employment or she responds with inappropriate anger to co-workers or supervisors, resulting in her dismissal. More recently, the psychologist noted that she had maintained steady employment at the Miami VA Hospital for a number of years, though here too, this pattern has emerged and led to her being transferred to different departments and reassigned to different supervisors. The Veteran’s August 2012 appellant brief reported that she was currently employed with VAMC Miami and works in the psychology department, after being transferred into that department due to the problems her mental condition has caused her at work. However, she has stated she still experiences problems with co-workers and her position duties, which exacerbate the symptoms of her condition. She noted that she regularly receives on-the-job mental counseling from her supervisor, the chief psychologist, when she feels overwhelmed by her symptoms and stated that she misses work two or more times per month due to her mental condition, and is late frequently due to sleep problems. She reported that her department has been lenient with her absences due to her condition and stated that she is approved for weekly therapy appointments that occur during work hours since March 2009. Thus, her attorney representative argued that although she is employed on a full-time basis, she appears to work in a protected environment that accommodates her condition. The Veteran further stated that she did not know how much longer her condition would allow her to continue in her duties at the Miami VAMC and that she would like to be admitted for private inpatient mental health treatment to improve her condition. At the August 2012 BVA hearing, the Veteran’s attorney reiterated that the Veteran’s psychiatric symptoms affected her work, and although she was able to work at the VA for a psychologist, she sometimes needed excuses from her doctor because she can’t go to work, and asserted that she was in a very protected position, including the opportunity to talk to a psychologist during the day to help her deal with problems. The attorney noted that she had tried other jobs and could not do them given her problems working with other people. The Veteran specifically testified that she had been working at the VA for 10 years and that her current position was the only good job she had at the VA because all her prior work departments resulted in problems. She stated that she was transferred there from another mental health position after a major issue with a supervisor and noted that she currently worked in the psychology service with “the best person that you could work for,” where things had been much better, and that she was there “to stay.” She believed that she would not last anywhere else, and that even so, at least two to three days per month, she had to call in sick and could not go in to work. She further reported social impairment, including problems getting along with family since her mom passed away in 2003 and reported strained relationships with her brother and sister, though she acknowledged they were “trying harder” and that she could count on them, as they are her only family and she wanted to keep those relationships. Additionally, the Veteran reported anxiety and uncomfortableness with socializing or going out, but also noted that she had two good friends, with whom she would attend art shows or go to the movies. She acknowledged that “sometimes [she] could be around other people, but it’s not really talking and socializing.” She denied any personal or intimate relationships for many years and said that she had one close friend that she saw “once in a while.” She stated that she could go to the grocery store and volunteered for a horse rescue to help her learn to be social. Treatment records from January 2013 document that the Veteran’s current GAF score remained at 50. She reported that she recently reduced interactions with family members and felt alone, isolated, and abandoned. However, she denied suicidal or homicidal ideation, audiovisual hallucinations, delusions, or mania. Upon mental status examination, she appeared alert and oriented, with casual dress, fair grooming, calm and cooperative manner, and intact speech and thoughts. In May 2014, the Veteran’s friend reported that he had known the Veteran since approximately 2007, when they met given their close work locations at the Miami VAMC. The friend observed that the Veteran was in constant conflict with her coworkers and supervisors almost every day until she was finally transferred to the psychology department. He noted that the Veteran was a good-hearted person and she joined various non-profit organizations on a few occasions, though these ended badly due to problems with the other members. The friend reported that he and his wife were the closest people the Veteran had for support, and she was no currently on speaking terms with any of her family members. In June 2014, the Veteran reported that she had to temporarily end her relationship with her family because she interpreted their behavior towards her as a lack of love. She stated that she had been in psychotherapy since 1992 and that she also now attended a 12-step fellowship program. She reported that she had not celebrated holidays for many years, since her mother died in 2003 and that she felt socially awkward and experienced anxiety, with symptoms that affected every area of her life. She noted that she had recently called into work for three days in a row because of the last anger outburst she had at recovery group. A June 2014 buddy statement from a friend of the Veteran for the past two years due to her involvement in the 12-step recovery community noted that the Veteran’s friendships seemed to be shaky because of her lack of trust, and that she did not have any intimate, close relationships since her divorce while serving in the Navy. The friend also observed that the Veteran would get extremely anxious around big crowds, and that she did not attend the large group meetings on Saturdays. During a June 2014 initial evaluation for private psychiatric treatment, the Veteran presented with low self-esteem, hypersensitivity, and anxiety. She reported that her relationships with her brother and sister were not going well, but noted supportive and fulfilling relationships with friends. Her reported psychiatric symptoms included sadness, crying spells, isolation, anxiety, panic attacks, flashbacks, fears, nightmares, worries, guiltiness, avoidance, inattention, sleep disturbances, anger, lack of energy, distrust, recurrent thoughts of traumatic experiences, and poor self-esteem. Her diagnosis included PTSD, dysthymic disorder, and generalized anxiety disorder (GAD), with a current GAF score of 51. A July 2014 mental disorders disability benefits questionnaire (DBQ) completed by the Veteran’s private physiatrist documents diagnoses of PTSD, dysthymic disorder, and GAD. Her psychiatric symptoms of depressed mood, anxiety, suspiciousness, impaired judgment, disturbances of motivation and mood, difficulty adapting to stressful circumstances (including work or a worklike setting), inability to establish and maintain effective relationships, isolation, flashbacks, nightmares, worries, guiltiness, avoidance, anger, lack of energy, and inattention were found to result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The examiner noted the Veteran had problems trusting people and concentrating at work. The Veteran’s occupational history included being transferred three times while working at the Miami VAMC because her mental health problems impacted her level of function at work. Additionally, it was noted that the Veteran was single, with not enough family support. A September 2014 letter from another private treatment provider reported that the Veteran had been receiving therapy for her conditions of chronic PTSD, dysthymic disorder, and GAD, with current symptoms including sadness, crying spells, poor self-esteem, recurrent thoughts of traumatic experiences, anxiety, flashbacks, worries, guiltiness, avoidance, inattention, sleep disturbances, isolation, fears, nightmares, anger, and mistrust. It was also noted that the Veteran reported difficulty tolerating being around other, though she had been very consistent attending to her individual and group therapy appointments. An October 2014 letter from a VA mental health professional reported that the Veteran had been experiencing PTSD symptoms since her military experiences, including repeated intrusive thoughts of traumatic experiences, chronic irritability and anger, clinically significant depression, moderate anxiety, chronic insomnia with frequent nightmares, poor concentration, marked self-isolation and avoidance of others, evident hypervigilance, and mistrust. It was stated that due to these severe symptoms (particularly avoidance, irritability, and anger), the Veteran had difficulty being in the presence of other individuals, and as a result, “she will have expected difficulties with securing and maintaining employment.” Upon follow up in April 2015, the Veteran continued to have difficulties with relationships with other people, including her family, which she remained distant from due to her belief that she did not prioritize her. She continued to be active in the adult children of alcoholics group therapy program, including having a sponsor, and found this to be helpful. Additionally, it was noted that her support system included friends and neighbors, in addition to her group sponsor, and that she remained employed by VA. In December 2015 a private vocational expert reported that since her traumatic in-service event, the Veteran had been experiencing psychiatric, emotional, and behavioral difficulties, which reportedly have affected all areas of her life. A review of her mental health records demonstrated that the Veteran had severe difficulties related to ongoing depressed mood, sleep and nightmares, anxiety, suspiciousness and paranoid ideations, impulsivity, irritability, and irrational anger outbursts, poor self-esteem, social isolation, avoidance of social events, difficulties forming and maintaining social, family, and personal relationships, difficulties maintaining concentration and motivation and memory, and difficulties in dealing with stressful work situations and interpersonal relationships with coworkers and supervisors. The private expert noted that her 70 percent disability rating for MDD with PTSD was based on occupational and social impairment with deficits in areas such as work, school, family, judgment, and mood, and that a review of the Veteran’s ongoing behavior and psychological symptoms indicated that she demonstrated symptoms and behaviors, which represent “serious impediments relative to the ability to maintain any type of substantial gainful occupation.” The expert stated that the Veteran’s GAF scores had consistently ranged from 50-60 throughout the years, and that GAF scores ranging from 51 to 60 indicate moderate symptoms or moderate difficulty in social, occupational, or school functioning, representing significant barriers in maintaining any type of employment. Regarding her education, she had attended classes in graphic design from March 1987-88 and completed an AA degree in accounting at Miami Dade College in 1998. Following discharge from active service, the Veteran worked in numerous clerical and office type jobs and as an office manager for a construction company, where she encountered difficulties dealing with supervisors and coworkers. She was either terminated from or quit these jobs, usually due to her inability to deal with stresses of the workplace and inappropriate responses to coworkers and supervisors precipitated by her psychiatric and emotional difficulties. She obtained employment with the VAMC as a Program Assistant for the mental health and behavioral services department in January 2002 and continued to work in her job to date, with accommodations that have been provided by her employer and supervisors. Specifically, the expert noted that she was not required to attend monthly staff meetings or luncheons, or social events within the department, and that she arrived late for work on a frequent basis, with frequent absences from work as she was able to put in for leave as needed. Thus, the expert concluded, based upon a review of the scope of accommodations that have been provided by VA, that “it is evident that the Veteran would not have been able to retain any type of employment by most employers within the general labor market over these years.” The expert asserted that government agencies generally provide work accommodations and more lenient absence and sick time benefits than non-governmental companies within the general labor market. Therefore, given what appears to be the permanency of the Veteran’s chronic anxiety, depression, and psychiatric difficulties and severe behavioral problems resultant of her MDD with PTSD, the vocational expert opined that the Veteran has been considered to be vocationally disabled and has been unable to perform any type of substantial gainful occupation within the general labor market since January 2007, and as such, she should also be considered to be entitled to a TDIU rating as of January 2007. Private treatment records from June 2016 document that the Veteran appeared alert and oriented, with participative behavior, depression and impulse control, but without any motor problems, and a current GAF score of 55. Private treatment records in the months thereafter document that her GAF scores went up to as high as 70 in November 2017, when she reported that she had a friend coming to visit her from Pennsylvania, although her GAF score lowered again to 60 in December 2016. A December 2017 letter from a private treatment provider noted that the Veteran had been compliant with her outpatient treatment, including follow-up appointments for medication management since 2002, as well as individual and group psychotherapy outside the VA system. She continued to suffer from chronic, daily PTSD symptoms, including depressed and anxious mood, anhedonia, distressing trauma-related intrusive memories, avoidance behaviors, hypervigilance, impaired sleep, and impaired concentration. She also suffered from comorbid persistent depressive disorder and insomnia, and it was felt that her chronic PTSD, depression, and insomnia continue to affect her ability to function in her social, interpersonal, and occupational roles. More recently, a January 2018 mental disorders DBQ completed by a VA examiner documents her ongoing diagnoses of MDD with PTSD (including insomnia, which the examiner stated was a symptom of her MDD with PTSD, rather than separate diagnosis). The examiner noted that her psychiatric symptoms of depressed mood, anxiety, chronic sleep impairment, flattened affect, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances (including work or a worklike setting), and neglect of personal appearance and hygiene, resulted in occupational impairment with reduced reliability and productivity. Regarding her social history, the Veteran reported that she had not been in a relationship since her time in the Navy, and although she was fearful due to her past personal trauma, she still desired companionship. She reported that her insomnia interfered with her relationships with family members and friends, as she would sometimes make plans on the weekends and could not follow through due to a lack of sleep or irritability. Regarding her education, she reported two and a half years of college, with experience working in photo labs prior to the military. During the military, she worked as an aviation structural mechanic in the Navy. Following the military, she worked in a printing business as a pre-press technician for ten years, and later at a car rental agency and then a construction company. She stated that currently she worked at the Miami VAMC as a Program Support Assistant in the Psychology Department, although she reported that mental health symptoms interfered with her occupational functioning. She stated that she arrived late for work a few times per week and had to use vacation time because she had not leave benefits when she arrived late. She often feels fatigued at work, with low energy and difficulty concentrating sometimes, and noted that she had difficulty with interpersonal relationships at work and sometimes avoids people. Upon mental status examination, she appeared alert and oriented, polite and cooperative, well-groomed and dressed, with goal-directed thoughts, normal psychomotor activity, and normal speech and eye contact. A February 2019 letter from the Interim Medical Center Director at the Miami VAMC congratulated the Veteran on her retirement after 24 years in federal government, including 17 years at the Miami VAMC. The Director noted that the Veteran had contributed to the compassionate delivery of patient care at the Miami VAMC, and that she should feel pride and satisfaction in the knowledge that she had served well and that her colleagues wished her a happy and healthy retirement. In July 2019, VA notified the Veteran that she was eligible for its vocational rehabilitation and employment (VR&E) program. However, in August 2019, her VR&E claim was discontinued due to a lack of cooperation or failure to participate, as the Veteran did not report for a scheduled appointment and did not provide enough information to make an entitlement determination. Given a review of the evidence of record, including as discussed in detail above, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to an initial disability rating in excess of 70 percent for MDD with PTSD, as her psychiatric symptomatology does not more closely approximate total occupational and social impairment for any period on appeal. Significantly, the probative evidence during the appeal period does not document total occupational and total social impairment manifested by such symptoms as suicidal ideation; obsessional rituals, which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; or neglect of personal appearance and hygiene or other symptoms of this level of severity. Rather, the evidence clearly documents that the Veteran has continued to function independently, without a significant partner or relationship, that she has consistently denied suicidal or homicidal ideation upon mental status examination, with normal speech, and the one isolated finding of neglect of personal appearance and hygiene within the January 2018 DBQ is internally inconsistent with the fact that the Veteran appeared well-dressed and well-groomed at the examination. Indeed, the evidence of record documents that the Veteran’s primary psychiatric symptoms have consistently been ongoing depression and anxiety, with chronic sleep impairment and insomnia, and irritability, though the Board notes that the Veteran is not shown to have a history of physical violence. Additionally, the Board has also considered the severity, frequency, and duration of the mental health symptoms displayed by the Veteran during the relevant period on appeal; however, the Board finds that the Veteran’s mental health symptoms, as discussed in the lay and medical evidence above, were not of such severity, frequency, and/or duration to more nearly approximate total occupational and total social impairment for any period on appeal. The Board does not disagree with the findings of the July 2014 DBQ, which found that the Veteran had occupational and social impairment with deficiencies in most areas, or an October 2014 letter from a VA mental health professional, which stated that the Veteran would have “expected difficulties with securing and maintaining employment,” or the finding of a December 2017 private mental health professional that the Veteran’s chronic PTSD, depression, and insomnia continue to affect her ability to function in her social, interpersonal, and occupational roles. However, to the extent that the December 2015 private vocational expert concluded that the Veteran’s occupational and social impairment with deficits in most areas represent “serious impediments relative to the ability to maintain any type of substantial gainful occupation,” and that the Veteran was vocationally disabled and had been unable to perform any type of substantial gainful occupation within the general labor market since January 2007, the Board disagrees. As discussed further below regarding the Veteran’s TDIU claim, the Board finds that the informal accommodations provided by the Veteran’s current employer at the Miami VAMC, including permission to skip monthly staff meetings, luncheons, or social events, and to arrive late for work or take leave from work as needed, do not equate to a finding that the Veteran experienced total occupational impairment related to her service-connected MDD with PTSD. Additionally, the findings within the July 2014 private DBQ and January 2018 VA DBQ, which specifically identified that the Veteran’s MDD with PTSD resulted in less than total occupational and social impairment, are consistent with her currently assigned 70 percent disability rating. While the adjudicator is responsible in determining, which disability rating is warranted, such conclusions that the Veteran’s impairment resulting from her service-connected MDD with PTSD is best described as meeting the disability rating criteria for less than total impairment is probative evidence against a finding that the Veteran’s service-connected psychiatric disability has resulted in total occupational and social impairment for the appeal period. Indeed, the Board notes that the Veteran’s current 70 percent disability rating for MDD with PTSD already contemplates deficiencies in most areas; however, she has not shown total occupational and total social impairment, which both must be present to warrant entitlement to a 100 percent disability rating. Moreover, even if the Board were to assume total occupational impairment, which it has not done, the probative evidence of record, including as discussed above, documents that the Veteran has not experienced total social impairment as a result of her service-connected MDD with PTSD for any period on appeal. Again, the Board does not disagree that the Veteran’s psychiatric symptoms have resulted in social problems, including negative interaction with coworkers or supervisors, and even strained relationships, including with close family members. However, the Board also finds it probative that throughout the appeal period, the Veteran had consistently engaged in group therapy, which would involve being around, and interacting with, other people, as well as individual therapy, which involves meeting one-on-one with a therapist in person. Moreover, the Veteran was consistently noted to be polite, participative, and cooperative within mental status examinations throughout the appeal period. Finally, the Board finds it probative that the Veteran has submitted several “buddy statements” in support of her claim. While these statements attest to her ongoing psychiatric symptomatology, they are also, in and of themselves, probative evidence that the Veteran has maintained some social connections, such that the Board cannot conclude that she experiences total social impairment. Moreover, the Veteran’s own statements, including her August 2012 Board hearing testimony, indicate that she has retained a few friends with whom she can interact, and that in spite of her strained family relationships at times, she reported that she wanted to maintain those relationships. As noted above, the Board has also properly considered the Veteran’s GAF scores of record, as her appeal was certified to the Board prior to August 4, 2014. See Golden v. Shulkin, 29 Vet. App. 589 (2018). Notably, the Veteran’s GAF scores during the appeal period have ranged from a low of 50 to a high of 70. While a GAF score of 41 to 50 reflects serious symptoms or serious impairment in social, occupational or school functioning, and scores ranging from 51 to 60 suggest moderate symptoms, or moderate difficulty in social, occupational, or school functioning, the Board notes that neither of these scores is indicative of total occupational or social impairment in and of themselves. Moreover, the Board ultimately places more probative value on the objective and narrative findings discussed above regarding the Veteran’s psychiatric symptomatology, which are far more descriptive (and therefore of more probative value) than the numerical GAF scores alone. The Board notes that the use of the GAF scale has been abandoned in the DSM-5 because of, among other reasons, “its conceptual lack of clarity” and “questionable psychometrics in routine practice.” See DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fifth edition, p. 16 (2013). This is another basis to accord more probative value to the specific clinical findings made by medical professionals while observing the Veteran during the examination than to the GAF scores alone. In sum, as the Veteran’s psychiatric symptoms due to her MDD with PTSD do not more closely approximate total occupational and total social impairment, she does not meet the rating criteria for an increased 100 percent disability rating for any period on appeal. Significantly, she has not shown the required severity of occupational and social impairment necessary for an increased 100 percent disability rating during the rating period, and her symptoms as a whole are not of similar severity, frequency, and duration as those particular symptoms associated with a 100 percent disability rating. As such, the preponderance of the evidence is against the Veteran’s claim of entitlement to an initial disability rating in excess of 70 percent for MDD with PTSD for the entire period on appeal, there is no reasonable doubt to be resolved, and the claim is denied. 2. Entitlement to a TDIU rating. The Veteran further alleges that she is precluded from securing or following a substantially gainful occupation due to her service-connected psychiatric disabilities. A TDIU rating may be granted upon a showing that the veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. There are minimum disability rating percentages that must be shown for the service-connected disabilities, alone or in combination, to qualify for consideration for a TDIU award under the schedular criteria. If there is only one such disability, it must be rated at 60 percent or more; if instead there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. In determining whether a veteran is unemployable for VA purposes, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. The central inquiry in determining whether a veteran is entitled to a TDIU rating is whether service-connected disabilities alone are of sufficient severity to produce unemployability. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough; a high disability rating itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. The ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; rather, it is a determination for the adjudicator. The Veteran is service connected for MDD with PTSD (rated as 70 percent disabling from January 1, 2007) and hypertension (rated as 10 percent disabling from January 19, 2010). Based upon the above, the Veteran’s 70 percent rating for one disability and combined disability rating of 70 percent from January 1, 2007 meets the schedular criteria for a TDIU rating for the entire period on appeal. However, following a review of the evidence of record, and as discussed below, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to a TDIU rating for the entire period on appeal. Within her July 2015 VA Form 21-8940, Veteran’s Application for Increased Compensation Based Upon Individual Unemployability, the Veteran asserted that she was prevented from securing or following any substantially gainful occupation by her service-connected psychiatric symptoms. She reported that she became too disabled to work on January 6, 1986, which date she also listed as the date that her disability affected full-time work; however, she further reported that she was still working full-time at the Miami VA hospital, where she had worked 40 hours per week in administrative positions from January 2002 to the present (a period of 13 years). The Veteran stated that although she continued to work, it was “becoming unbearable.” She additionally reported an educational history including two years of college, with additional education or training at graphic design school from March 1987-88. Without duplicating its discussion of the evidence of record, discussed in detail above, the Board initially notes that the evidence is clear and uncontested that the Veteran worked continuously at the Miami VAMC since approximately 2002 to the time of her retirement in 2019—a period of 17 years, where she worked full time. The allegation in her TDIU application that she became too disabled to work as of 1986 is refuted by her 17 years of full-time work at VA. The Veteran has also consistently reported problems at work related to her service-connected psychiatric symptoms, including conflicts with coworkers and supervisors that resulted in her being transferred on approximately three different occasions, most recently in early 2010 when she was transferred to a position in the psychology department, where she remained until her retirement. The Veteran and her attorney generally assert, including with an August 2012 appellant brief and during the August 2012 Board hearing, that despite her continuous employment from 2002-19, the Veteran’s federal government position essentially constitutes a protected work environment with accommodations for her service-connected psychiatric condition, which should be considered marginal employment for purposes of determining eligibility to a TDIU rating. The Board is mindful that under 38 C.F.R. § 4.16(a), marginal employment shall not be considered substantially gainful employment. Marginal employment shall be found if a veteran’s income does not exceed the poverty threshold established by the U.S. Census Bureau or, when income does exceed the poverty threshold, it may be shown on a facts found basis, which includes, but is not limited to, employment in a protected environment. Id.; Ortiz-Valles v. McDonald, 28 Vet. App. 65, 71 (2016). Although VA has not defined what constitutes work “in a protected environment,” the Board nevertheless must consider its applicability on a facts found basis. After a review of the evidence, however, and as discussed below, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to TDIU rating for the entire period on appeal. The Board also specifically finds, as discussed further below, that the Veteran’s employment at the Miami VAMC from approximately 2010 to 2019 does not constitute work in a protected environment consistent with marginal employment. The Board has considered evidence that the Veteran reported within an August 2012 appellant brief that she regularly received on-the-job mental counseling from her supervisor when she felt overwhelmed by her symptoms. Additionally, she stated that she missed work two or more times per month due to her mental condition and was frequently late due to sleep problems. She also noted that her department was lenient with her absences due to her condition and approved her attendance at weekly therapy appointments that occurred during work hours since March 2009. The Veteran again asserted at the August 2012 Board hearing that she worked in a “very protected position,” including having the opportunity to talk to a psychologist during the day to help her deal with problems. The Veteran also testified that she had tried other jobs and could not do them. She believed that she would not last anywhere else, and that even in her VAMC position, she had to call in sick at least two to three days per month. The Board finds that the Veteran’s lay reports regarding her use of leave are consistent with a provided summary of the Veteran’s leave used at VA from January 2015 to February 2018, which documents that during that period of just over three years, the Veteran used 42 hours of authorized absence, 582.25 hours of annual leave, 6.5 hours of compensatory time, 6.5 work credit hours, 295.50 hours of sick leave, and 914 hours of leave without pay. The Board notes that the report does not specify the exact reasons for the Veteran’s use of each category of leave, though the Board assumes based upon the Veteran’s reports that at least some portion of the Veteran’s use of sick leave was related to her service-connected psychiatric disability. Additionally, the Veteran has stated that, at times, she was forced to utilize annual leave in lieu of sick leave for her psychiatric symptoms. Nevertheless, even acknowledging the Veteran’s use of sick leave, the Board does not equate this with a finding of a protected work environment, as no doubt, the Veteran’s coworkers at VA, as well as every other federal employee, were also each accumulating and using sick leave and annual leave at their leisure. Stated another way, the accumulation and use of work leave is not an accommodation given to select employees, such as the Veteran, but a work benefit accorded to the work population in general. Additionally, to the extent that the Veteran asserts that having the opportunity to talk to a psychologist during the day or receiving approval to attend weekly therapy appointments during work hours constituted work in a protected environment, the Board again disagrees. The record does not document a formal request for concessions made by the Veteran or any formal accommodations provided to the Veteran by VA as a result of her service-connected MDD with PTSD. Moreover, while the Board does not find such reports to lack credibility, the Board nevertheless finds that such practices seem to be more informal allowances that were an inherent beneficial feature of the Veteran’s administrative position in a VA psychiatric department, rather than specific accommodations made for her service-connected disability, much like a cashier might request several, even frequent, opportunities throughout the day to utilize restroom breaks for relief of duties inherent to that position. Similarly, the Board finds the preponderance of the evidence is against a finding that the Veteran’s service-connected psychiatric disability resulted in lost income, or that legally required accommodations (i.e., those pursuant to the Americans with Disabilities Act) where required for the Veteran to maintain her substantially gainful employment. The Veteran was working full time from 2002 to 2019, and thus there is affirmative evidence of substantially gainful employment during this time period. The Board has also carefully considered the December 2015 opinion of a private vocational expert that the Veteran’s ongoing behavior and psychological symptoms represent “serious impediments relative to the ability to maintain any type of substantial gainful occupation” and that “it is evident that the Veteran would not have been able to retain any type of employment by most employers within the general labor market over these years” based upon accommodations provided by her government agency employer. In sum, the vocational expert opined that the Veteran has been considered to be vocationally disabled and has been unable to perform any type of substantial gainful occupation within the general labor market since January 2007, and as such, she should also be considered to be entitled to a TDIU rating as of January 2007. However, for the reasons discussed above, the Board affords lessened probative weight to the private vocational expert’s opinion, as the Board has found that the alleged work accommodations do not, in fact, constitute marginal employment based upon work in a protected environment. Moreover, the Board finds that the vocational expert’s review of the Veteran’s educational and occupational history provides probative evidence, which also weighs against the claim for a TDIU rating. The expert noted that the Veteran had previously attended classes in graphic design from March 1987-88, as well as had an AA degree in accounting at Miami Dade College in 1998. Additionally, following service discharge, she worked in numerous clerical and office-type jobs and as an office manager for a construction company. Though she admittedly encountered difficulties dealing with supervisors and coworkers in these positions due to her psychiatric symptomatology, the Board finds that her education and varied employment would enable her with skills that would allow her to thrive in a number of positions that would accommodate her psychiatric symptoms. The Board is mindful that the Veteran most often reported difficulty being around or dealing with others in the workplace; however, she could utilize her college education and administrative and computer skills to work remotely for a variety of employers from home or another location that would not involve direct contact with others. No doubt, the federal government, including the Veteran’s VA employer, offers robust telework opportunities, as well as numerous options within the private sector. Moreover, this type of work-from-home scenario would also potentially allow for flexibility in her work schedule to accommodate mental health appointments, treatment, or other required breaks. In conclusion, the Board finds that the preponderance of the evidence is against a finding that the Veteran was precluded from securing and maintaining substantially gainful employment due to her service-connected disabilities for any period on appeal. While the record is clear that the Veteran’s service-connected disabilities have a functional impact on her ability to work, including primarily as related to her MDD with PTSD; however, as discussed above, the probative evidence of record weighs against a finding that such impairment has resulted in the inability to secure or follow a substantially gainful occupation for any period on appeal. The Veteran has a combined disability rating of 70 percent, which the Board finds compensates the Veteran for the impact that her service-connected disabilities have on her ability to work. The 70 percent rating for MDD with PTSD contemplates deficiencies in work, which the Veteran’s disability picture falls under this description. As such, the Board finds that any resulting impairment of function is adequately contemplated by the current disability ratings assigned for the Veteran’s service-connected disabilities. In sum, for all the reasons discussed above, the Board finds that the Veteran’s service-connected disabilities, when considered individually and collectively, do not result in functional impairment, which renders the Veteran unable to secure or follow a substantially gainful occupation consistent with her educational and vocational history. Therefore, entitlement to a TDIU rating is denied for the entire period on appeal. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Chad Johnson, 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.