Citation Nr: 20028093 Decision Date: 04/22/20 Archive Date: 04/22/20 DOCKET NO. 15-15 840 DATE: April 22, 2020 ORDER Entitlement to an evaluation higher than 50 percent prior to February 8, 2017 for posttraumatic stress disorder is denied. REMANDED The issue of entitlement to a total disability rating based on individual unemployability (TDIU) prior to February 8, 2017 is remanded. FINDING OF FACT Prior to February 8, 2017, the Veteran’s PTSD was productive of occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW Prior to February 8, 2017, the criteria for an evaluation higher than 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1974 to September 1974. The instant claim was among those denied by the Board in a July 2018 decision. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court), which in July 2019 vacated that part of the Board’s decision that denied a higher evaluation and TDIU prior to February 8, 2017. Evaluation of PTSD prior to February 8, 2017 A February 2010 compensated work therapy (CWT) intake note indicates the Veteran’s report of experience as a driver. He expressed interest in the medical field, mailroom, and warehouse type work. The provider noted a history of drug use and acknowledged the Veteran’s need to develop a relapse prevention plan. In June 2010, the Veteran expressed interest in obtaining a commercial driver’s license. He reported that he had possessed one previously, and needed help getting it renewed. He related that he would search for positions in waste management once his license was renewed. In July 2010, the Veteran reported that he had an interview with a trucking company and that he was willing to work in their warehouse until he obtain his commercial driver’s license. He related that he had recently come up positive on a mandatory program urinalysis because he had taken an old prescription. The provider cautioned the Veteran that he might be subject to pre-hire drug testing while actively seeking employment. An October 2010 VA mental health record notes the Veteran’s report of working in the CWT program and being satisfied with his employment situation. In November 2010, the Veteran inquired about available employment opportunities. Subsequently that month, he reported to his mental health provider that he would be completing the CWT program and intended to return for work with VA. In April 2011, the Veteran denied using illicit substances in the previous week. The provider directly assessed the Veteran for suicidal ideation or intent, and noted that the Veteran denied both. Subsequently in April 2011, the Veteran stated that he had remained clean since his last visit and that he had approached two employers. He indicated that he felt good about his chances of securing employment. He denied suicidal and homicidal ideation or intent. His mood was visibly happy. A May 2011 VA mental health individual therapy note indicates that the Veteran and provider reviewed the Veteran’s partially completed application to the Topeka VA Medical Center’s PSTD clinic. The provider noted that the Veteran became visibly angry when she stated her belief that the statements in the application could be perceived as angry and rude. The provider explained to the Veteran that part of her job was to provide him with feedback regarding how he was perceived by others. The remainder of the session was spent assisting the Veteran how to process his anger and how he might provide responses on his application without being perceived as rude. The provider noted that the Veteran was able to calm down through processing the situation, and that by the end of the session, he appeared to be in a good mood. He denied suicidal or homicidal ideation or intent. In June 2011, the Veteran reported that his mood was “fine” and that his appetite was good. He indicated that sleep was poor, and that attention and concentration were fair. He indicated that he was not sober and that his last use of cocaine was a week previously. He denied suicidal ideation over the past month. In July 2011, the Veteran reported that he had approached volunteer services at his VA Medical Center and expected to be hired as a volunteer there. In August 2011, the Veteran denied suicidal and homicidal ideation or intent. His mood was euthymic and his affect was congruent with mood. In October 2011, the Veteran reported that he would keep seeking work until he was employed. He denied suicidal and homicidal ideation. No other issues were voiced. In January 2012, the Veteran reported that he had applied for a job but was not hired. He related his belief that persistence could take him somewhere, and indicated that he had been seeking other opportunities. The provider noted that the Veteran appeared to be coping well with the stressors in his life. She indicated that he denied suicidal and homicidal ideation. A February 2012 VA mental health individual therapy note indicates the Veteran’s report that he had spent the week in bed due to frustrations with his family. He related that he felt overwhelmed interacting with them because he did not know how to regulate his boundaries. The provider helped him explore the ways he might set boundaries and modify them. He voiced no other issues. He denied suicidal and homicidal ideation. Subsequently in February 2012, the Veteran presented to a VA emergency department, where a VA provider assessed him and determined that his suicide risk was high. On mental status examination, the Veteran expressed suicidal thoughts with a plan. He was threatening toward staff. Insight and judgment were impaired. He admitted to smoking crack cocaine that morning. Involuntary commitment procedures were initiated. The day following admission, a provider noted that the Veteran had been admitted with urine toxicity screen positive for cocaine and opioids. Objectively, he was cooperative, with normal speech and motor functioning. Mood was depressed. Thoughts were clear, without formal thought disorder. The Veteran denied current suicidal or homicidal ideation. Insight and judgment were limited. The assessment was substance induced mood disorder, cocaine abuse, and opioid abuse. The Veteran declined rehabilitation. On individual therapy, the Veteran was advised that substance use could interfere with his medication and with psychotherapy. His mood appeared euthymic and affect as congruent. Thought content was logical and goal-directed. The Veteran did not voice suicidal or homicidal ideation or intent. The plan was to discharge the Veteran the following day. Prior to hospital discharge, the Veteran stated that he felt good about discharge. His mood was euthymic. Thought content was logical and goal-directed. He denied suicidal or homicidal ideation or intent. Suicide risk assessment was conducted, and the provider determined that the Veteran was at low risk. In March 2012, the Veteran related that his inpatient admission had helped him. He denied current suicidal ideation. He reported that his mood was “OK” but appeared to be down. He reported good sleep and appetite. He was alert and oriented. Speech was normal. Mood was sad and affect was restricted. Thought process was linear, productive, and logical. There was no evidence of suicidal or homicidal ideation. Insight and judgment were noted to be improving. The provider indicated that the Veteran was at low risk for suicide. In April 2012, the Veteran expressed interest in CWT. The provider noted that he had successfully completed such a program in 2010. A June 2012 VA mental health homeless veteran housing program screening note indicates the Veteran’s report that he and his girlfriend broke up in December 2010 and he became homeless. The Veteran stated that his goals for the VA assisted housing program were to remain sober, obtain housing, and obtain employment. In July 2012, mental status examination revealed euthymic mood and full affect. The Veteran was fully oriented, and his speech was normal. Thought process was linear, productive, and logical. There was no suicidal or homicidal ideation, and no delusions. Insight and judgment were noted to be improving. On screening for a VA transitional work experience (TWE) program in July 2012, the Veteran expressed an interest in truck driving. Work skills and abilities were noted to be mail room, truck driving, and shipping and receiving. The Veteran reported that he had last worked as a cement truck driver in 2001, and had left that job due to drug use. He related that, since service, he had been unable to hold a job for more than 18 months due to substance use. The provider determined that the Veteran met the criteria for re-admission into the TWE program, but that it was recommended that he first complete a substance abuse program. In August 2012, the Veteran reported that he coped with feelings caused by group therapy by thinking about his dogs. He noted that, otherwise, he had been struggling with feelings of anger and confusion. He indicated that his partner had questioned why he was snapping at her. He stated that he had not realized how much little things were bothering him. He indicated his intent to be more aware of this and walk away and also to ask his partner to make him aware of his behavior in the moment so he could walk away and regroup. He stated that he otherwise felt good and indicated that he was going to get his own apartment soon. He denied suicidal and homicidal ideation. On VA examination in October 2012, the examiner indicated diagnoses of PTSD and polysubstance abuse in early full remission. He stated that it was possible to differentiate the symptoms attributable to each diagnosis. He noted that the Veteran’s polysubstance abuse was in early full remission, and indicated that current symptoms were attributable to PTSD. He indicated that PTSD was productive of occupational and social impairment with reduced reliability and productivity. He identified depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The Veteran reported that he was divorced and lived alone, but had a fiancée. He indicated that the CWT program was his most recent job, and that he had held multiple jobs since service. He related that he had been jailed three times, all for drug offenses. In December 2012, the Veteran reported that he continued to have nightmares, but that they did not happen as often. He related that he had a feeling of empowerment as he continued to talk about his experience and make changes in his life. He denied suicidal and homicidal ideation. He again denied suicidal and homicidal ideation in January 2013. A VA mental health supported housing interim note in January 2013 indicates that the Veteran was contacted by telephone. He was oriented and alert. He spoke in a clear and lucid manner. His mood was euthymic. Thought process was clear. No over psychiatric disturbance was evidenced. A subsequent January 2013 mental status examination report indicated that the Veteran was oriented and alert. Speech was normal, and thought process was linear, productive, and logical. The Veteran’s mood was euthymic and affect was full. There was no indication of suicidal or homicidal ideation, and no delusions. Insight and judgment were noted to be improving. In March 2013, the Veteran stated that his nightmares continued, but that he was coping. He reported that he had decided to take guardianship of his great niece. He denied suicidal and homicidal ideation. A subsequent March 2013 therapy record indicates that the Veteran felt good about his involvement with his family. He stated that he had no complaints. He denied suicidal and homicidal ideation. A March 2013 VA mental health supported housing record notes that the Veteran was doing very well and continued advancement with his PTSD work. He related that he had maintained a stable relationship with a woman for more than a year. His apartment was noted to be neat and clean. The Veteran was casually dressed and appropriately groomed. He maintained appropriate eye contact, was cooperative, pleasant, and appropriately engaged in the interview. His speech was of normal rate, rhythm and volume. His mood was euthymic, and his affect was congruent and appropriate to situation and discussion. Thought processes appeared logical and goal directed. No delusions, obsessions, or compulsions were noted in thought content. No abnormal perceptions were noted. The Veteran appeared fully alert and oriented with no gross sensorial defects apparent. Memory, attention and concentration appeared intact and appropriate. Insight and Judgment appeared fair. An April 2013 VA mental health treatment plan note indicates that the Veteran was stable with no current risk to himself or others. He had good insight into his problems and noted to be actively addressing them. He reported that he continued to have a close relationship with his siblings. Regarding education, he reported that he graduated from high school and attended community college for one year following service. He indicated that his employment history included driving a truck and warehouse work. He reported that he was off drugs and that he had a girlfriend. An April 2013 VA individual therapy record indicates the Veteran’s report of feeling good. He related that his nightmares had decreased, and suggested that this was due to a reduction in overall stress. He indicated a desire to return to work after he had recovered from recent spine surgery. He denied suicidal and homicidal ideation. In June 2013, the Veteran reported that since his brother’s death the previous month, he did not feel like doing anything. He shared that despite having cravings to use drugs, he had not. He denied suicidal and homicidal ideation. A June 2013 VA mental health attending note indicates that the Veteran was alert and oriented. Speech was normal. His mood was euthymic and affect was full. Thought process was linear, productive, and logical. There was no suicidal or homicidal ideation, and no delusions. Insight and judgment were fair. A July 2013 VA individual therapy note indicates the Veteran’s report of a panic attack while shopping when someone bumped into him from behind. The provider explained that the Veteran was under increased stress and that this might have reduced his tolerance level. The Veteran also shared that he felt suicidal on the night before his birthday as he was thinking about his brother and significant other. He indicated that he called a friend and talked and was given good advice from the friend. He stated that he sought employment at Goodwill, but was told that the only positions available would require him to lift boxes, which he could not do because of physical disability. The Veteran denied suicidal and homicidal ideation. In August 2013, the Veteran reported experiencing a panic attack the previous week. He noted that these episodes were occurred more frequently. He was advised on various methods of dealing with these episodes. He reported that he was granted admission to a VA domiciliary program. He related that he was taking care of his responsibilities and following as needed. He denied suicidal and homicidal ideation. In October 2013, the Veteran reported that he had to leave the VA inpatient treatment program early due to an illness in his family, and that his sister had subsequently died due to cancer. He denied suicidal and homicidal ideation. An October 2013 VA mental health attending note indicates the Veteran’s report of not completing the inpatient treatment program due to his sister’s illness. He related that he was moving forward with his life, and that he intended to continue therapy. Mental status examination revealed full orientation. Speech was normal. The Veteran’s mood was euthymic and affect was full. Thought process was linear, productive, and logical. There was no indication of suicidal or homicidal ideation, or delusions. Insight and judgment were fair. A November 2013 VA mental health treatment plan report indicates that the Veteran was alert, oriented, and clear. His mood was noted to fluctuate from calm to angry or irritable; however, the provider noted that his mood was mainly even and upbeat, but anxious at times when processing feelings of grief or loss. The provider noted that the Veteran seemed to be actively grieving the loss of his sister but was using coping skills effectively. The Veteran indicated that he had a positive support system. The provider noted that the Veteran sometimes exercised poor judgment, based on his tendency to only want to do things his own way. She indicated that the Veteran was guarded at times, but was able to establish rapport. She noted that he was motivated to maintain his independence, but had difficulty ambulating since hip surgery. She noted that the Veteran had a history of polysubstance abuse and had maintained sobriety for four years. She concluded that the Veteran appeared to be coping well in general and that he did not express any suicidal or homicidal intent or plan. A February 2014 VA individual therapy note indicates the Veteran’s report that he was not doing well due to hip pain. He expressed concern over how he would support himself when he was in so much pain. He denied suicidal and homicidal ideation. A subsequent February 2014 record notes the Veteran’s report of a panic attack over the previous weekend. He endorsed difficulty sleeping. He denied suicidal and homicidal ideation. In February 2014, the Veteran sought assistance with the USA JOBS website. He was instructed in how to establish an account and how to apply for positions. A February 2014 VA mental health attending note indicates the Veteran’s report of continued sleep issues. He indicated that he was not taking prescribed Sertraline, as he felt suicidal on that medication. He denied current suicidal or homicidal ideation. On mental status examination, he was alert and oriented. Speech was normal. His mood was euthymic and affect was full. Thought process was linear, productive, and logical. There were no delusions. Insight and judgment were fair. A March 2014 VA mental health attending note indicates the Veteran’s report of continuing sleep issues. He denied suicidal and homicidal ideation. On mental status examination, he was oriented and alert. His mood was euthymic and affect was full. Thought process was linear, productive, and logical. Thought content was negative for delusions. Insight and judgment were fair. A March 2014 VA individual therapy record notes the Veteran’s report that he was dealing with his military sexual trauma as well as the deaths of family members. He related that his sleep was better with a medication change. He noted that, overall, he felt better able to cope with situations rather than be overwhelmed by his emotions. The provider indicated that the Veteran continued to make improvements in his ability to cope emotionally. He denied suicidal and homicidal ideation. A May 2014 VA mental health counseling note indicates the Veteran’s report that he had been applying for jobs, but that he was finding that employers were not willing to hire him given his recent surgery and two impending surgeries. He indicated that he continued to experience nightmares, but that he would watch television upon waking to feel better. He denied suicidal and homicidal ideation. A May 2014 VA mental health attending note indicates that the Veteran had no complaints. He denied worsening symptoms of PTSD. The provider noted that the Veteran was not on any medications for PTSD. On mental status examination, the Veteran was alert and oriented. Speech was normal. The Veteran’s mood was euthymic and affect was full. Thought process was linear, productive and logical. There was no suicidal or homicidal ideation, and no delusions. Insight and judgment were fair. A June 2014 VA mental health individual therapy note indicates the Veteran’s report that he and his partner had a heated argument on Father’s Day. He indicated that he had been angrier recently, but trying to do better. He related that following the argument, he felt bad and apologized. The provider noted that while processing this, the Veteran indicated that he was able to feel closer and thus more vulnerable to his partner. He agreed that his behavior may have been an unconscious attempt to push her away. No other issues were voiced. The Veteran denied suicidal and homicidal ideation. A July 2014 VA individual therapy note indicates the Veteran’s report that he applied for a job in VA housekeeping. His ongoing recovery process was discussed, and the Veteran related that he felt good about where he was. He denied suicidal and homicidal ideation. A subsequent July 2014 VA mental health individual therapy note reflects discussion of the Veteran’s ongoing challenges with his partner and his great niece. He described how he had coped during a disagreement with his partner. He denied suicidal and homicidal ideation. Subsequently in July 2014, the Veteran endorsed good mood. He indicated that he felt good about his progress. He related that he still had difficulty going to Wal Mart, but that he had less difficulty going to the drug store. He denied suicidal and homicidal ideation. An August 2014 VA mental health individual therapy note indicates the Veteran’s report of having difficulty concentrating on “lots of things” and trying to put everything into perspective. He related that he felt frustrated, but that his life was better than when he was using drugs. He reported that he was filing for Social Security Administration disability benefits. He denied suicidal and homicidal ideation. A September 2014 VA mental health attending note indicates that the Veteran had no complaints. He denied worsening symptoms of PTSD. The provider noted that the Veteran was not on any medications for PTSD. On mental status examination, the Veteran was alert and oriented. Speech was normal. The Veteran’s mood was euthymic and affect was full. Thought process was linear, productive and logical. There was no suicidal or homicidal ideation, and no delusions. Insight and judgment were fair. A September 2014 report indicates that the Veteran had been provided with a vocational rehabilitation orientation, but that he had failed to complete the required comprehensive evaluation. An October 2014 VA mental health supported housing note indicates that the provider visited the Veteran at his apartment. The provider indicated that the apartment was clean, had working utilities, and a good amount of household furnishings. Objectively, the Veteran was well groomed. He was cooperative and pleasant, with a bright mood. He had good eye contact with the provider. Speech was spontaneous and clear, with appropriate volume and rate. He was alert and oriented. Thought content was coherent, logical, and goal-oriented. No suicidal or homicidal ideation or intent was expressed. Insight and judgment were fair. A November 2014 VA mental health attending note indicates no complaints. The Veteran denied worsening of PTSD symptoms and indicated that he was on no medications for PTSD. On mental status examination, the Veteran was alert and oriented. Speech was normal. The Veteran’s mood was euthymic and affect was full. Thought process was linear, productive and logical. There was no suicidal or homicidal ideation, and no delusions. Insight and judgment were fair. A February 2015 VA mental health attending note indicates that the Veteran was taking medication to help him sleep. He reported no worsening of his PTSD symptoms. He denied recent confrontations or arguments. On mental status examination, the Veteran was alert and oriented. Speech was normal. The Veteran’s mood was euthymic and affect was full. Thought process was linear, productive and logical. There was no suicidal or homicidal ideation, and no delusions. Insight and judgment were fair. A May 2015 VA mental health individual therapy note indicates the Veteran’s report that he continued to have difficulty going to Wal Mart due to anxiety. He also expressed frustration over his inability to work due to physical limitations. He reported coping by reading his Bible and sitting in his apartment. He denied suicidal and homicidal ideation. A June 2015 VA mental health individual therapy note indicates the Veteran’s report of continued nightmares and difficulty going to Wal Mart. He related that he was otherwise doing well overall. He denied suicidal and homicidal ideation. A July 2015 VA mental health attending note indicates the Veteran’s denial of worsening symptoms. On mental status examination, the Veteran was alert and oriented. Speech was normal. The Veteran’s mood was euthymic and affect was full. Thought process was linear, productive and logical. There was no suicidal or homicidal ideation, and no delusions. Insight and judgment were fair. A February 2016 VA mental health attending note indicates that the Veteran was mainly focused on his medical issues. On mental status examination, the Veteran was alert and oriented. Speech was normal. The Veteran’s mood was euthymic and affect was full. Thought process was linear, productive and logical. There was no suicidal or homicidal ideation, and no delusions. Insight and judgment were fair. An April 2016 VA mental health supported housing note indicates that the Veteran was visited in his apartment. The apartment was clean and fairly neat. The Veteran related that he had attempted to work for a temporary agency to supplement his income, but that he was unable to keep that job due to his medical conditions. Objectively, the Veteran was clean, appropriately dressed, and well groomed. His behavior was cooperative, and he was pleasant and in a bright mood. Good eye contact was displayed and the Veteran was engaged in the interview. His speech was spontaneous and clear, with appropriate volume and rate. He was alert and oriented. Thought content was coherent, logical and goal-oriented. No suicidal or homicidal ideation or intent was expressed. Insight and judgment were fair. A May 2016 VA mental health note indicates the Veteran’s report of continued difficulty around crowds. He indicated that he planned to take his grandsons to a movie, and ways to minimize the stress of attending were discussed. The provider noted that the Veteran did not appear to be in acute distress, and noted that he seemed to have maintained progress from previous therapy. He denied suicidal and homicidal ideation. A May 2016 VA supported housing interim note indicates that the Veteran was referred for job development. He was provided assistance in preparing his resume. He expressed interest in truck driving school. Subsequently in May 2016, a VA provider transported the Veteran to a truck driving school so that he could submit an application. He expressed excitement at the prospect of being employed as a truck driver. A June 2016 VA mental health administrative note indicates that Veteran sought vocational services. He was advised to request a vocational services consultation through his mental health provider. A June 2016 VA mental health telephone note indicates the Veteran’s report that he was “fantastic”. He related that the vocational counselor had determined that he was unqualified for truck driving school, and that he had decided that he wanted to attend seminary. Objectively, the Veteran’s speech was clear and he spoke in a normal tone. He was pleasant. He was coherent and thought content was goal-directed. He voiced no suicidal or homicidal ideation. An August 2016 VA supported housing interim note indicates that the Veteran was provided transportation, then interviewed in his apartment. The residence was clean and there were no safety concerns. The Veteran reported that he continued to maintain his apartment and pay his rent on time. He related that he attended church regularly and had considered becoming a preacher. He indicated that his family remained a good source of support. Veteran was clean, appropriately dressed for the weather, and well groomed. His behavior was cooperative, he was pleasant and in a bright and jovial mood. Good eye contact was displayed, and the Veteran was noted to be engaged. His speech was spontaneous and clear, with appropriate volume and rate. The Veteran was alert and oriented. Thought content was coherent, logical and goal-oriented. No suicidal or homicidal ideation or intent was expressed. Insight and judgment were fair. A September 2016 VA mental health individual therapy note indicates the Veteran’s report of nightmares most nights since his most recent session. He denied suicidal and homicidal ideation. An October 2016 VA mental health attending note indicates the Veteran’s report of suicidal ideation on certain psychotropic medications. He declined medication. On mental status examination, the Veteran was alert and oriented. Speech was normal. The Veteran’s mood was euthymic and affect was full. Thought process was linear, productive and logical. There was no suicidal or homicidal ideation, and no delusions. Insight and judgment were fair. On psychosocial assessment in November 2016, the Veteran was pleasant and appropriate. He was alert, oriented, and clear. The provider noted that the Veteran’s mood fluctuated between calm and angry or irritable, but that it was even and upbeat. Anxious mood was noted when the Veteran processed feeling of grief or loss. The provider noted that the Veteran seemed to be actively grieving the loss of his sister, but was using coping skills effectively. The Veteran indicated that he had a positive support system available, which primarily included his fiancée and extended family. He was noted to exercise poor judgment at times per his tendency to only want to do things his own way. He was also noted to be guarded at times, but engaged after building rapport. He related that he was motivated to maintain his independence, but noted that he had difficulty ambulating since hip surgery. He reported that he was managing his activities of daily living independently. The provider noted the Veteran’s history of polysubstance abuse and his maintenance of sobriety for four years. The provider noted that the Veteran was actively engaged in mental health treatment and appeared to respond well to treatment. The provider also noted that the Veteran appeared to be coping well in general and did not express any suicidal or homicidal ideation or plan. A November 2016 VA mental health individual therapy note indicates the Veteran’s report of increased nightmares. He related his need for more time alone as his memories surfaced. No other issues were voiced. He denied suicidal and homicidal ideation. A November 2016 VA homeless program note indicates that the Veteran was visited at his apartment. It was neat, with working utilities. No safety issues were noted. Objectively, the Veteran was clean, appropriately dressed, and well groomed. His behavior was cooperative, and he was pleasant and in a bright mood. Good eye contact was displayed and the Veteran was engaged in the interview. His speech was spontaneous and clear, with appropriate volume and rate. He was alert and oriented. Thought content was coherent, logical and goal-oriented. No suicidal or homicidal ideation or intent was expressed. Insight and judgment were fair. In February 2020, a VA examiner interviewed the Veteran and reviewed the record. She concluded that she was unable to ascertain, without resorting to mere speculation, whether the Veteran’s VA hospitalization in February 2012 for suicidal plan was due to service-connected PTSD. She noted that this was particularly the case since the Veteran is unable to provide a statement regarding his own recollection of the events occurring on that day due to loss of verbal communication secondary to stroke. The examiner noted that when she asked yes or no questions, the Veteran was able to respond, but that he demonstrated a response bias answering yes, sometimes verbally saying yes, other times shaking his head up and down, to almost all questions. The examiner additionally noted that there were historical details that the Veteran’s daughter could not respond to because she had reportedly not always maintained a relationship with her father, thereby making her unable to speak to historical matters, specifically the February 2012 hospitalization in question. Disability evaluations are determined by the application of a schedule of ratings based on average impairment in earning capacity. 38 U.S.C. § 1155 (2012). Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2019). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2019). VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. If there is a question as to which evaluation to apply to the Veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2019). Under 38 C.F.R. § 4.130, Diagnostic Code 9411, a 50 percent evaluation is warranted for PTSD when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo-typed 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. A 70 percent evaluation is warranted when 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 work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: 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 and place; memory loss for names of close relatives, own occupation, or own name. Id. The “such symptoms as” language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means “for example” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, “[w]without those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous.” Id. The Court went on to state that the list of examples “provides guidance as to the severity of symptoms contemplated for each rating.” Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. VA is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The reasonable doubt doctrine dictates that all symptoms be attributed to the veteran’s service-connected disability. See Mittleider, 11 Vet. App. at 181. Having carefully reviewed the evidence of record, the Board concludes that a higher evaluation is not warranted for the Veteran’s PTSD for the period prior to February 8, 2017. During the appellate period, the Veteran’s reported and observed symptoms included sleep disturbance, irritability, depressed mood, anxiety, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. During regular contact with VA social workers and his psychiatrist, his mood was noted to be good or euthymic, with congruent affect. Providers observed that the Veteran appeared to be coping well with his stressors, and that he had a good support system consisting of family and significant others. During regular contact with his social workers and psychiatrist, the Veteran was noted to be coping well with his symptoms and was receptive to feedback on how to improve his coping skills. He was regularly found to be alert and oriented, with normal speech and thought processes. The Board acknowledges that during therapy in May 2011, the Veteran expressed anger when provided feedback on an application for an inpatient PTSD program. However, the provider noted that the Veteran was able to calm down and process his anger with her assistance. Overall, the record indicates that the Veteran’s interactions with his VA providers were positive and effective. The Board also acknowledges that the Veteran was admitted for two days in February 2012 after he presented at a VA emergency department reporting that he was suicidal and had a plan. He was threatening toward staff. Insight and judgment were impaired. The Board observes, however, that he also reported having smoked crack cocaine that morning. Urine toxicity screen was positive for cocaine and opioids. The following day upon individual therapy with the therapist who regularly followed the Veteran, he was cooperative. His mood was depressed, but his thoughts were clear. He denied suicidal or homicidal ideation, and his mood was euthymic with congruent affect. Prior to discharge, the Veteran expressed that he felt good. On suicide risk assessment, he was noted to be at low risk. In February 2020, a VA examiner stated that she could not ascertain whether the Veteran’s February 2012 hospitalization had been due to his service-connected PTSD. She pointed out that the Veteran had suffered loss of verbal communication due to a stroke, and that his daughter was unable to provide a historical account. Thus, the record remains unclear as to whether the Veteran’s PTSD prompted his suicidal intent that led to his hospital admission. In any event, as discussed in detail, the record otherwise reflects the Veteran’s routine denial of suicidal and homicidal ideation during very regular contact with his VA providers. The record also indicates the Veteran’s reported difficulty being in public places, to include his report of a panic attack in July 2013 when someone bumped into him while he shopped. At that time, the Veteran also reported that he had felt suicidal on the night before his birthday, but that he had called a friend who helped him process those feelings. He denied current suicidal ideation. In February 2014, he reported that he had stopped taking a prescribed mediation secondary to feeling suicidal on that medication. Overall, the record for this period otherwise reflects the Veteran’s repeated denial of suicidal and homicidal ideation, to include on the day following his admission in February 2012. Moreover, the Board concludes that his isolated reports of panic episodes do not rise to the level of the near continuous panic or anxiety necessary to meet the criteria for a 70 percent evaluation. The Board acknowledges the Veteran’s reports of irritability and its effect on his relationships; however, he generally reported good relationships with family and significant others, and an effective support system. Thus, it cannot be stated that he is unable to establish and maintain effective relationships. While the Board accepts that the Veteran’s PTSD affected his functioning during the period in question, the record as a whole does not demonstrate that there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Reports of regular contact with VA social workers, therapists, and a psychiatrist demonstrate euthymic mood and full affect, normal speech and thought process, and that the Veteran was alert and oriented. He repeatedly denied thought disorder, and none was noted. Aside from one episode of suicidal intent and plan, a report of suicidal ideation that resolved upon seeking help from a friend, and a report that certain medications caused suicidal thoughts, the Veteran denied suicidal ideation and intent. Although he reported episodes of panic and anxiety going into public places, the record does not reflect near continuous panic. Thus, it cannot be said that the evidence as a whole for the appellate period reflects occupational and social impairment of the severity contemplated by the criteria for a 70 percent evaluation. In summary, the overall disability picture does not more nearly approximate the criteria for a schedular evaluation of 70 percent. As such, the Board concludes that an evaluation of 50 percent is appropriate for the Veteran’s PTSD. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND 1. TDIU prior to February 8, 2017 TDIU may be assigned, where the schedular rating is less than total, when a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: disabilities of one or both upper extremities or of one or both lower extremities, including the bilateral factor, if applicable; disabilities resulting from common etiology or a single accident; disabilities affecting a single body system; multiple injuries incurred in action; or multiple disabilities incurred as a prisoner of war. Id. For the period prior to February 8, 2017, the Veteran was in receipt of VA disability benefits for PTSD, evaluated as 50 percent disabling; umbilical hernia repair, evaluated as noncompensably disabling; and erectile dysfunction, evaluated as noncompensably disabling. Thus, he did not meet the schedular requirements for TDIU for this period. When the percentage requirements are not met, entitlement to TDIU may be considered on an extraschedular basis when the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign extra-schedular TDIU in the first instance. See Bowling v. Principi, 15 Vet. App. 1 (2001). Rather, where there is a question as to whether the Veteran is unable to secure or follow a substantially gainful occupation the issue requires referral to the Director of the Compensation Service, for a determination in the first instance as to whether the Veteran is entitled to TDIU on an extra-schedular basis under 38 C.F.R. § 4.16(b). Because the Veteran and his attorney maintain that he experiences difficulty with occupational functioning due to his PTSD, the Board concludes that this case should be referred for extraschedular consideration. The matters are REMANDED for the following action: 1. Refer the issue of entitlement to TDIU prior to February 8, 2017 to the Director of the Compensation Service for extraschedular consideration under 38 C.F.R. § 4.16(b). 2. Then, readjudicate the Veteran’s claim, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Barone, 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.