Citation Nr: 21004257 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 16-54 755 DATE: January 26, 2021 ORDER Entitlement to an initial rating in excess of 30 percent for an anxiety disorder not otherwise specified (NOS) is denied. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU) is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s the anxiety disorder NOS with associated symptom of suspiciousness is manifested by symptomatology resulting in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication without occupational and social impairment with reduced reliability and productivity due to such symptoms, occupational and social impairment with deficiencies in most areas, and total social and occupational impairment. 2. Throughout the period on appeal, the evidence did not show that the Veteran’s service-connected disabilities rendered him unable to obtain and maintain substantially gainful employment due to service-connected disabilities. 3. At no time during the pendency of the claim does the Veteran have a current diagnosis of PTSD, and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of a claim. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 30 percent for anxiety disorder NOS have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.125, 4.126, 4.130, Diagnostic Code 9413. 2. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 3. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1970 to March 1973. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. Jurisdiction of this appeal is currently with the RO in San Diego, California. This case was previously before the Board in September 2018, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. Specifically, the RO was instructed to afford the Veteran a VA psychiatric examination to determine the nature and etiology of his claimed PTSD. The RO conducted the development and returned the appeal to the Board for appellate action. Then, the case was again before the Board in July 2020. At that time, the Board noted that the instant matters were certified to the Board in April 2020 and the Veteran and his representative were notified of this in an April 7, 2020 letter. In a May 2020 submission, the Veteran’s representative requested that the Veteran’s claims be held open for the full 90-day period, until July 6, 2020, to allow for the submission of additional argument. This requested time period had expired and additional evidence or argument has not been received. However, at the time of the July 2020 Board decision, a second request for extension for an additional 60 days that had been submitted in July 2020 by the Veteran’s attorney and had not yet been associated with the record. Accordingly, in October 2020, the Board vacated the July 2020 Board decision to allow the Veteran and his attorney the second requested 60 day period to allow for the submission of additional evidence. The second Motion for Extension of Time was granted by the Board in October 2020. This requested time period has again expired, and additional evidence or argument has not been received despite the Board granting the Veteran and his attorney’s requests for extensions to submit such evidence. Therefore, the Board will, again, proceed with adjudication of the Veteran’s claims. The Board again notes that in a May 2008 submission, the Veteran’s representative argues that the VA examinations of record were inadequate as the examiners did not provide a valid rationale for diagnosing the Veteran with a personality disorder or declining to diagnose PTSD. However, the VA examiners did provide an explanation in support of the diagnoses and distinguished the symptoms related to each diagnosis. To the extent that the Veteran’s representative argues that the Veteran has not been diagnosed with a personality disorder by his treatment providers and therefore the diagnosis of a personality disorder during the VA examinations is invalid, this assertion is factually incorrect. The Veteran underwent a neuropsychological consultation in November 2013 that resulted in a diagnostic impression of a personality disorder that was made following a review of the record, an examination of the Veteran and extensive psychological testing. In addition, a personality disorder was noted in mental health treatment notes dated in September 2004, June 2005 and in July 2005. The Board notes that these treatment records predate the first VA examination in this case, which occurred in October 2007. The Veteran’s representative essentially disagrees with the diagnoses rendered by various VA mental health professionals. This argument is without merit. The Board again notes that the issue of entitlement to service connection for a traumatic brain injury (TBI) has been raised by record repeatedly in statements by both the Veteran and his representative beginning with a December 2014 notice of disagreement. Additionally, the August 2016 statement of the case (SOC) indicated that the issue of entitlement to service connection for a TBI would be adjudicated by the Agency of Original Jurisdiction (AOJ) in a separate rating decision. In the September 2018 Board remand and July 2020 Board decision, the Board noted that the issue had not yet been adjudicated by the AOJ, and thus the Board did not have jurisdiction over it, and referred the issue to the AOJ for appropriate action under 38 C.F.R. § 19.9(b). Again, the Board notes that issue has not been adjudicated by the AOJ, and notes that no action whatsoever has been taken regards to this issue. This issue is not before the Board and will not be addressed herein. ACCORDINGLY, THE BOARD AGAIN REFERS THE ISSUE OF ENTITLEMENT TO SERVICE CONNECTION FOR A TBI TO THE AOJ FOR APPROPRIATE ACTION. 38 C.F.R. § 19.9(B). Increased Rating – Anxiety Disorder NOS The Veteran contends that he is entitled to a rating in excess of 30 percent for his anxiety disorder NOS as such disability is more severe than as reflected by the currently assigned rating. I. Pertinent Legal Criteria Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 3 8 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran’s service-connected anxiety disorder NOS is evaluated under the criteria of Diagnostic Code 9413, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Effective November 7, 1996, Diagnostic Code 9413 provides that a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Code 9413. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation...requires an ultimate factual conclusion as to the Veteran’s level of impairment in most areas.” Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130, Diagnostic Code 9413. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.” 38 C.F.R. § 4.126(a). In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-V). See 38 C.F.R. § 4.130. The Board notes that the revised DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (Aug, 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, No. 16-1208 (February 23, 2018). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claim. II. Relevant Medical Evidence A review of the record reveals that the Veteran has exclusively sought mental health treatment from VA facilities, as well as treatment for his other health needs. To the extent that the Veteran’s VA treatment records contain information relevant to the severity of his mental health, to include mental health screenings, the Board will summarize this evidence. Turning to the evidence, the clinical evidence of record reflects that the Veteran endorsed psychiatric symptomatology that included fighting and physical altercations; legal problems, to include being arrested for not paying child support; drug use; alcohol use; domestic violence; anger; lack of friends and/or social interaction; being easily frustrated; irritability; suspiciousness; severe impact upon interpersonal relationships; difficulty maintaining employment; paranoid ideation; persecutory and paranoid delusion; impaired judgment; impaired insight; inappropriate behavior; poor impulse control; episodes of violence; guardedness; defensiveness; paranoia; difficulty getting along with others at work; difficulty trusting others; cognitive issues; aggressive behavior; forgetfulness; paranoid thinking; pressured and rambling speech; racing and circumstantial thinking; mood swings; insomnia, depression, extreme hopelessness, disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or worklike setting; and an inability to establish and maintain effective relationships. Notably, a November 2013 VA treatment record indicates the Veteran was seen for a neuropsychological evaluation in October 2013. After examination and interview of the Veteran, the examiner opined that the Veteran’s significant psychiatric symptoms of aggressiveness, suspiciousness, adjustment, and personality traits were likely to be as a combination of pre-existing traits and his mood disorder. The Veteran was afforded a VA psychiatric examination in October 2007. At that time, he reported he engaged in physical altercations as a child, and that he experienced racism. He reported he had difficulty controlling his anger. He reported he was married, but that he was no longer intimate with his wife and was not sure if he loved her anymore. He indicated he had been charged with domestic violence, and instructed to get anger management. He did not get anger management, and the domestic violence charge was not pursued. He stated he did not have any friends, and described much suspicion of others. He denied alcohol use after 1989, but indicated he used drugs to “regulate the pressures in [his] body.” The examiner noted the Veteran had not received any mental health treatment since April 2006, and that there was no documentation of any psychiatric symptoms from the previous year. The Veteran reported irritability and frustration with others and denied depression. The examiner noted that the Veteran was highly guarded and had suspiciousness that was constant over the last year. Behavioral observations by the October 2007 VA examiner showed the Veteran presented as clean; neatly groomed; appropriately and casually dressed; restless; with rapid, loud, pressured, and obscure speech; attitude that was suspicious, contemptuous, and irritable; full affect; mood that was angry and irritable; oriented to person, time, and place; thought process that was rambling, racing, evasive, overabundance of ideas, circumstantiality; thought content that was paranoid; persistent persecutory and paranoid delusion; impaired judgement; average intelligence; partially impaired insight; inappropriate behavior; poor impulse control; and episodes of violence. The examiner noted the Veteran did not describe a systematized delusional belief system, but that he “very well may have one.” The examiner diagnosed intermittent explosive disorder, polysubstance abuse in sustained full remission, and paranoid personality disorder. The Veteran was afforded another VA psychiatric examination in January 2013. At that time, the examiner diagnosed anxiety disorder NOS that was moderate-severe. The examiner noted that the Veteran’s reported symptoms were “difficult to discern,” due to his difficulty communicating specific symptoms related to specific experiences. However, the examiner found the Veteran’s symptoms of anxiety were related to his military experiences; and that the symptoms of anxiety were present at the time of his enlistment and significantly aggravated by his military experience. The examiner also found the Veteran had diagnoses of personality disorder NOS with antisocial personality disorder traits, polysubstance abused in full remission since 2001, and intermittent explosive disorder. The examiner noted the Veteran had significant difficulty resisting aggressive impulses as a result of his intermittent explosive disorder. The January 2013 VA examiner found the Veteran had more than one mental disorder diagnosed, but that it was possible to differentiate symptoms attributable to each diagnosis. Symptoms attributed to his anxiety disorder NOS included restlessness; difficulty with concentration; irritability; anger; sleep disturbance; re-experiencing intrusive thoughts; depressive symptoms including emotional numbing; and hypervigilance. Symptoms attributed to his personality disorder NOS included: suspects, without sufficient basis, that others are exploiting, harming, or deceiving him; preoccupation with unjustified doubts of trustworthiness of friends or associates; is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him; bears long-term grudges; consistent irresponsibility; inability to sustain employment; failure to conform to social norms with respect for lawful behaviors; and impulsivity. The examiner noted that due to the full remission of the Veteran’s polysubstance abuse, it was unlikely that anxiety was related to the substance abuse; however, the use of drugs and involvement in the drug culture was likely to contribute to his personality disorder symptoms. The examiner opined the Veteran’s psychiatric symptoms manifested in occupational and social impairment with deficiencies in most areas; and that it was not possible to differentiate what portion of the occupational and social impairment indicated was caused by each mental disorder. In this regard, the examiner noted that the Veteran’s anxiety and personality disorder symptoms were strongly interconnected. Specifically, his inability to trust and interact with others, as well as the trauma history symptoms, result in a highly anxious and disorganized presentation. However, when related to occupational impairment, the anxiety demonstrated in decreased reliability due to lack of sleep; inability to attend due to hypervigilance; irritability with coworkers; and distraction from intrusive thoughts. The examiner noted that the occupational impairment related to his personality disorder symptoms included significant issues with authority; paranoia; lack of trust of other coworkers and supervisors; and impulsivity. Symptoms reported at the January 2013 VA examination time included depressed mood; suspiciousness; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; and impaired impulse control, such as provoked irritability with periods of violence. Upon mental status examination, the Veteran appeared as clean; well-groomed; casually-dressed; restless; guarded, especially at first; speech that was mumbling, fast speech, tangential at times, difficult to redirect; non-linear thought process; anxious affect; anxious mood at first, with improvement throughout the interview; oriented to person, time, and place; no impairment in memory; and no deficits in attention or concentration. The Veteran was observed to have delusions, that included conspiracies related to the government; and visual and auditory hallucinations. He had obsessive compulsive behaviors and looked for patterns in “7s.” He had sleep problems in that he slept only 3 hours a night. He did not have panic attacks. He endorsed passive suicidal thoughts, but did not have suicidal ideation. He had one historic suicide attempt. He did not have homicidal ideation, but did have a history of violent behaviors beginning in high school. The Veteran also endorsed the following: considerable distress with intrusive thoughts and difficulty dismissing memories; moderate distress but manageable with some disruption of activities when getting emotionally upset when being triggered and reminded of an event; moderate physical reactivity when something reminded him of the event; moderate avoidance of thoughts or feelings; moderate avoidance of certain activities; moderate loss of interest in activities; severe marked feelings of detachment or estrangement from most people; moderate definite reduction of emotional experience but still able to experience most emotions; severe sense of foreshortened future; difficulty falling asleep and extreme long latency; moderate irritability or attempts to suppress anger; and severe hypervigilance. The Veteran was afforded another VA psychiatric examination in August 2016. At that time, he reported continued sustained full remission of polysubstance abuse. The examiner diagnosed other specified personality disorder (paranoid personality disorder, traits; antisocial personality disorder, traits), and other specified anxiety disorder. The examiner found the Veteran had more than one mental disorder diagnosed, and that it was possible to differentiate what symptoms were attributable to each diagnosis. Specifically, the examiner found that suspiciousness could be attributed to his other specified anxiety disorder, and was also attributed in part to his personality disorder. Symptoms attributed to his other specified personality disorder included suspiciousness; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and an inability to establish and maintain effective relationships. The examiner noted the primary driver in the Veteran’s difficulties was his personality disorder. His personality disorder and associated difficulties in communicating with others, connecting to others, and establishing relationships with others leads to constant conflict and confusion, which was stressful and maintained his on-going anxiety. He denied friendships of any kind, but reported he helped his landlord with their autistic child. Behavioral observations by the August 2016 VA examiner showed the Veteran presented as an unreliable historian to some unknowable extent; became very agitated; raised his voice; called the examiner a “homosexual”; walked out of the session; aggressive; agitated; difficulty and being “scared” of psychologists; expressed threatening behavior towards the examiner and his wife who was present; grandiose ideations; oriented to person, time, and place; appropriate memory and executive function; poor impulse control, with regular impulsive violence; self-reports of insomnia; and irritability. The examiner noted the Veteran had symptoms of suggested grandiosity and narcissism; had unrealistic ideas of his ability to communicate; and chronic difficulties in trusting others. The examiner opined the Veteran’s psychiatric symptoms resulted in occupational and social impairment with deficiencies in most areas. Finally, the Veteran was afforded a VA psychiatric examination in September 2019. At that time, the examiner diagnosed paranoid personality disorder with antisocial traits and other specified anxiety disorder and that there is “weak evidence to continue” the diagnosis of other specified anxiety disorder. The examiner noted that the information for the opinion was gathered using standardized psychological testing with symptom validity scales, the Veteran’s presentation and self-report during the clinical interview and a review of the available records. In that regard, the examiner noted the Veteran described minimal anxiety symptoms, and what he does describe were likely driven by the cognitive distortions and suspiciousness of his paranoid personality disorder. Furthermore, the examiner noted the Veteran’s self-report style was likely exaggerated, based on objective symptom validity testing, further weakening support for the diagnosis and related impairment. Specifically, the examiner noted that the Veteran’s response style produced an invalid clinical profile due to exaggerated responding, that current testing was not able to aid in diagnostic clarification, that validity scales from the psychological testing indicate that the Veteran understood the items and responded to them in a manner that was consistent with their content and that a failure to comprehend the items cannot serve as an explanation for the over endorsement of symptoms. As a result, the examiner determined that the Veteran’s self-report throughout the current interview if of questionable validity due to exaggeration and should only be sued cautiously for diagnostic and rating purposes. The examiner explained that the Institute of Medicine had concluded that a validity assessment was necessary in psychological evaluations for disability examinations as their review of research found that the use of clinical judgment alone to assess if an individual is providing accurate self-report of symptoms is unreliable and that it is important for the evaluator to collect and consider test data along with other objective data in making such assessment. The examiner further noted that formal Symptom Validity Tests exists to objectively assess the validity of data obtained during psychological assessment and that a through psychological assessment may include the analysis of internal data consistency, examination of corroborative evidence and formal Symptom Validity Tests. In contrast, the September 2019 examiner found that the Veteran’s paranoid personality disorder’s manifested in symptoms of a pervasive distrust and suspiciousness of others such that the motives were interpreted as malevolent; suspects, without sufficient basis, that others are exploiting, harming or deceiving him; reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him; reading hidden demeaning or threatening meanings into benign remarks or events; perceives attacks on character or reputation that are not apparent to others; quick to react angrily or to counterattack; impulsivity; failure to plan ahead; irritability; aggressiveness; consistent irresponsibility, as indicated by failure to sustain consistent work behavior or honor financial obligations; and broad deviation in cognitions, affectivity, interpersonal functioning. The examiner noted that the Veteran had made claims of being the victim of racism or otherwise targeted, that the prominence of racism in this country against people of color cannot be denied and that the evidence suggests a psychopathy due to the Veteran’s claims of being targeted and his life-long response pattern of physical aggression due to the perception of being targeted. The examiner noted that this psychopathy reflects a broad deviation in cognition, affectivity, interpersonal functioning and impulse control supports a finding of paranoid personality disorder with some antisocial-type traits. The September 2019 examiner found the Veteran had more than one mental disorder diagnosed, and that it was possible to differentiate what symptoms were attributable to each diagnosis. Specifically, the examiner found that suspiciousness could be attributed to his other specified anxiety disorder, and was also attributed in part to his personality disorder. Symptoms attributed to his paranoid personality disorder with antisocial traits included suspiciousness; impaired judgment; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner opined the Veteran’s occupational and social impairment as a result of his anxiety disorder was manifested by occupational and social impairment due to mild or transient symptoms. The examiner noted that “if the paranoid personality disorder with antisocial traits [was] included, the impairment level would more likely reflect occupational and social impairment with deficiencies in most areas.” Behavioral observations showed the Veteran presented as clean; casually dressed; adequate eye contact; adequate hygiene; physical appearance within normal limits; normal level of activity; initially defensive and suspicious, but became more cooperative; speech that was normal in rate and rhythm; oriented to all spheres; good mood, but wondered by everyone seemed to be smiling at him; congruent affect; thought content and progression with often loose associations, paranoid thoughts, vague descriptions; and a reported impaired memory, but without showing overt problems with memory, concentration, and attention. The September 2019 VA examiner indicated symptoms that actively applied to the Veteran’s other specified anxiety disorder included suspiciousness. The examiner further noted that if the symptoms for the paranoid personality disorder with antisocial traits was included, then the following symptoms would also have been indicated: impaired judgment; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. III. Analysis As an initial matter, the Board notes that, in addition to his service connected anxiety disorder NOS, the Veteran has been diagnosed with other psychiatric disorders, to include his paranoid personality disorder with associated traits for which service connection has not been granted. The Board finds that it is possible to differentiate the symptoms and manifestations of his nonservice-connected psychiatric disorder from his service-connected anxiety disorder NOS as will be discussed herein. See Mittleider v. West, 11 Vet. App. 181 (1998). Based on the foregoing, the Board finds that the Veteran’s service-connected anxiety disorder NOS is associated with suspiciousness, resulting in, at most, occupational and social impairment due to mild or transient symptoms without occupational and social impairment with reduced reliability and productivity due to such symptoms, occupational and social impairment with deficiencies in most areas, and total social and occupational impairment. Therefore, a rating in excess of 30 percent for such disorder is not warranted. In this regard, while the Veteran has reported additional psychiatric symptomatology, to include significant anger; violent outbursts; impaired judgment; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting, such have been attributed to his nonservice-connected paranoid personality disorder. Therefore, they cannot serve as a basis for awarding an increased rating for his anxiety disorder NOS. See Mittleider v. West, supra. Furthermore, while the August 2016 VA examiner indicated that the Veteran’s psychiatric symptoms resulted in occupational and social impairment with deficiencies in most areas, the August 2016 and September 2019 VA examiners nonetheless attributed only suspiciousness to his service-connected anxiety disorder. Moreover, the August 2019 VA examiner explained that if the Veteran’s other psychiatric symptoms attributable to his paranoid personality disorder would be included, his occupational and social impairment would more closely approximate deficiencies in most areas. However, when considering only the symptoms of suspiciousness attributed to his anxiety disorder, the Veteran’s occupational and social impairment more closely approximated impairment due to mild or transient symptoms. The Board notes that the January 2013 VA examiner attributed restlessness; difficulty with concentration; irritability; anger; sleep disturbance; re-experiencing intrusive thoughts; depressive symptoms including emotional numbing; and hypervigilance to the Veteran’s anxiety disorder NOS; and opined that the Veteran’s psychiatric symptoms manifested in occupational and social impairment with deficiencies in most areas. However, the VA examiner found that it was not possible to differentiate what portion of the occupational and social impairment indicated was caused by each mental disorder because the anxiety and personality disorder symptoms were strongly interconnected. This finding is consistent with the August 2019 VA examiner’s explanation that if all of the Veteran’s psychiatric symptoms would be considered, occupational and social impairment would more closely approximate deficiencies in most areas. Further, with regard to the Veteran’s social functioning, the record reflects that he has been married throughout the appeal period and indicated he had a friendly relationship with his landlord and landlord’s autistic child. In this regard, to the extent that the Veteran reports that he has difficulty in his marriage and difficulty in social interactions, such is noted to be the result of his extreme aggression, anger, and paranoia, which, as noted above, have been attributed to his nonservice-connected paranoid personality disorder. In regard to his occupational functioning, to include difficulty in adapting to stressful circumstances, including work or a worklike setting, the Board notes that the Veteran has not worked at any point pertinent to the appeal period. However, as indicated previously, the Veteran is not service-connected for his paranoid personality disorder, and review of the records reflects that all of his service-connected and nonservice-connected psychiatric symptoms resulted in his inability to maintain steady employment. Specifically, the Board notes that the September 2019 VA examiner attributed the Veteran’s consistent irresponsibility, as indicated by his failure to sustain consistent work behavior or honor financial obligations to his nonservice-connected paranoid personality disorder. Moreover, the September 2019 VA examiner indicated that the Veteran’s anxiety disorder resulted in minimal anxiety symptoms, and that the symptoms described were likely driven by the cognitive distortions and suspiciousness of his paranoid personality disorder. In that regard, the examiner found that there was weak evidence to continue a diagnosis of an anxiety disorder and any related impairment to such diagnosis. Furthermore, to the extent that the Veteran, as well as his spouse, contend that his anxiety disorder is more severe than currently evaluated, the Board observes that they have not considered the impact of his additionally diagnosed nonservice-connected paranoid personality disorder on his social and occupational functioning. Consequently, while they are competent to report observable symptomatology, they are not competent to relate such specific symptoms, and their resulting impact on his social and occupational functioning, to a specific diagnosed disorder. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, while the Board accepts the Veteran’s and others’ assertions with regard to the matters each are competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. In a May 2018 submission, the Veteran’s representative argued that a 100 percent rating was warranted for the Veteran’s anxiety disorder NOS as it was not possible to separate the effects of the conditions and that the January 2013 VA examiner could not separate the occupational and social impairment caused by his service connected anxiety disorder NOS and his nonservice-connected personality disorder. In addition, the Veteran’s representative argued that the October 2007 and August 2016 VA examinations were inadequate for VA purposes; and that the RO should have relied on the January 2013 VA medical opinion. The Veteran’s representative asserts that due to his difficulty communicating, frequent episodes of agitation, aggression, impaired impulse control, and difficulty getting along with others, that the Veteran is essentially unemployable and therefore his psychiatric symptoms should be rated as at least 70 percent disabling. As discussed above, August 2016 and September 2019 VA examiners were able to differentiate psychiatric symptoms and attributed only suspiciousness to his service-connected anxiety disorder. The September 2019 VA examiner explained that when assessing only the symptom of suspiciousness, the Veteran’s occupational and social impairment more closely approximated impairment due to mild or transient symptoms. The Board finds these opinions highly probative as the examiners reviewed the claims file, interviewed the Veteran, and provided an opinion supported by a clear rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is no contrary probative opinion of record. Moreover, as noted above, the January 2013 VA examiner determined that the Veteran’s anxiety and personality disorder were strongly interconnected and was able to differentiate the level of occupational impairment attributable to the service connected anxiety disorder and nonservice-connected personality disorder. These arguments are without merit. To the extent that the Veteran’s representative argued that the occupational and social impairment attributable to his symptoms could not be separated, the Board notes that the VA examiners addressed both the symptoms and resulting functional impairments attributable to his service connected anxiety disorder and the nonservice-connected personality disorder. While the Veteran’s representative argued that the Veteran’s agitation during an August 2016 VA examination was attributable to his service connected anxiety disorder and that such agitation would interfere with his occupational functioning, the examiner specifically attributed the Veteran’s difficulties communicating with others and connecting to others are attributable to his nonservice connected personality disorder. Moreover, the examiner detailed the Veteran’s agitation, which included leaning forward in his chair, raising his voice, calling the examiner a homosexual, walking out the session and talking about how he had a history of being aggressive towards people who angered him. The examiner further noted that the Veteran displayed difficulties trusting the examiner, that he enlisted his wife to calm him down during the interview, and that he then displayed threatening behavior towards his wife during the interview. Nowhere in this examination report is it suggested that the Veteran was unable to complete the examination due to anxiety; rather, the examiner attributed the Veteran’s suspiciousness, disturbances of mood and difficulties adapting to stressful circumstances to his nonservice connected personality disorder. Therefore, these arguments are without merit. The Board has also considered whether staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected anxiety disorder; however, the Board finds that his symptomatology referable to such disability has been stable throughout the period on appeal. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Board notes that the Veteran’s representative has submitted a Board decision in another veteran’s case in support of the instant claim. Board decisions are not precedential. 38 U.S.C. § 7104; 38 C.F.R. § 1303; Hillyard v. Derwinski, 1 Vet. App. 349, 351 (1991). Moreover, the Board decision submitted by the Veteran’s representative remanded that particular veteran’s case for further development pursuant to a Joint Motion for Remand and the relevance of this Board decision is not clear. The Board is therefore affording no probative weight to this submission. The Board notes that the Veteran’s representative submitted an article about the clinical administered PTSD scale, personality disorder clusters, and what appears to be an excerpt from the DSM-5 Diagnostic and Statistical Manual of Mental Disorders. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. §§ 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). However, treatise evidence must “not simply provide speculative generic statements not relevant to the [claimant]’s claim.” Wallin v. West, 11 Vet. App. 509, 514 (1998). Instead, the treatise evidence, “standing alone,” must discuss “generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion.” Id. (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (medical treatise evidence must demonstrate connection between service incurrence and present injury or condition); Beausoleil v. Brown, 8 Vet. App. 459, 463(1996) (generic statement about the possibility of a link between chest trauma and restrictive lung disease is too general and inconclusive); Mattern v. West, 12 Vet. App. 222, 227 (1999) (generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive (quoting Sacks, supra)). In this case, the articles submitted by the Veteran’s representative provided only general information as to the diagnosis of various psychiatric disorders. It is not accompanied by any corresponding clinical evidence specific to the Veteran and does not suggest that the Veteran has somehow been misdiagnosed such that, under the facts of this specific case, reflects plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. As such, the Board finds this information to not be relevant as to the matter for consideration and, therefore, is not probative to this case. Wallin, supra; Sacks, supra. Further, in reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s increased rating claim. As such, that doctrine is not applicable in the instant appeal, and his increased rating claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to a TDIU The Veteran asserts he is entitled to a TDIU. Specifically, his representative argues that if the Veteran’s anxiety disorder is rated at 70 percent disabling, the Veteran should also be granted a TDIU. In that regard, the Veteran has not worked since 2001, and that should his psychiatric disability be rated at 70 percent disabling, the Veteran would satisfy the schedular requirements of a TDIU. Total disability ratings for compensation 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). Rating boards should submit to the Director of Compensation Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to a TDIU is based on an individual’s particular circumstances.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran’s 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran’s master’s degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In the instant case, the Veteran is service-connected for anxiety disorder NOS, rated 30 percent from July 23, 2001. This is his only service connected disability. The Veteran’s combined rating from July 23, 2001 is 30 percent. Thus, the schedular criteria for TDIU have not been met. However, when a Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for a TDIU set forth in 38 C.F.R. § 4.16(a), the case may be referred to appropriate VA officials for consideration of assignment of a TDIU rating. 38 C.F.R. § 4.16(b). Here, the evidence is against finding that the Veteran is precluded by his service connected disability from obtaining and maintaining any form of gainful employment consistent with his education, experience, and skillset. The record shows that the highest level of education attained by the Veteran is three years of high school and one year of college completed, and that he began vocational training as a machine tool operator in the 1980s. The Veteran obtained a GED. He also reported working as a TV repairman and car mechanic prior to active service. During service, the Veteran’s military occupational specialty (MOS) included motor transport operator. Thereafter, the record shows that the Veteran last worked in 2001 as a laborer. The ultimate question is whether he is capable of performing the physical and mental acts required by employment, not whether he can find employment. 38 C.F.R. § 4.16(a); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). At an October 2007 VA psychiatric examination, the Veteran reported he last worked full time in 2001 as a laborer in construction. He reported he had difficulty following instructions, and that he was fired because he asked for repeated instructions. The reasons provided for his unemployment included carpal tunnel in his wrist resulting in an inability to lift; joint pain when lifting; joint cramping; carpal tunnel in both wrists; right shoulder pain; neck pain; and anger. He also reported that he would get in trouble at work for asking others to help him; and that he had difficulty getting along with others at work, in large part because he had difficulty trusting others. The examiner noted that the Veteran had been highly guarded and suspicious of others on a consistent basis, and that this personality dynamic severely impacted upon his interpersonal relationships and ability to hold a job. An October 2013 VA examination indicated that the Veteran’s traumatic brain injury residuals did not impact his ability to work. A November 2013 VA treatment record indicates the Veteran reported his headaches interfered with his work a lot, and that he did not have a stable working history after leaving college. At an August 2016 VA examination, the examiner indicated the Veteran’s primary driver of difficulties was as a result of his paranoid personality disorder. In that regard, the Veteran’s personality disorder and associated difficulties resulted in difficulty communicating with others, connecting to others, and establishing relationships with others; leading to constant conflict and confusion. Moreover, the examiner noted that the Veteran’s paranoid personality disorder prevented the effective relationships needed to maintain regular employment. A September 2016 VA treatment record indicates the Veteran reported he had interest in assistance with obtaining gainful employment. Based on the foregoing, and in consideration of the pertinent medical findings, including his reports at the various VA examinations of record and during treatment at VA medical centers, where he indicated his barriers to employment included problems getting along with others; pain and mobility issues in his wrists and shoulder; anger; headaches; and confusion, the Board finds that the Veteran is not unable to secure and follow a substantially gainful occupation by reason of his service connected anxiety disorder. In this regard, as discussed in the preceding section, the Veteran’s anxiety disorder NOS has been found to result in, at most, occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Thus, such disability is not shown to render the Veteran unable to secure or follow a substantially gainful occupation. The Board notes that the Veteran is only service connected for an anxiety disorder and the functional impairments related to his wrists, shoulders and headaches are not for consideration. Specifically, at the September 2019 VA examination, it was found that his anxiety disorder NOS resulted in only mild impairment, and did not render him unable to secure work. In that regard, the examiner indicated that there was weak evidence to continue his diagnosis of anxiety disorder NOS. Similarly, the VA examiner found that, while the Veteran’s combined psychiatric disabilities resulted in considerable degree of social and occupational impairment, his nonservice-connected paranoid personality disorder were primarily responsible for his social and occupational impairment in most areas. Moreover, the Board notes that the Veteran himself asserts that he is unemployable as a result of a combination of his physical limitations and mental health symptoms. In that regard, the Veteran included carpal tunnel in his wrist resulting in an inability to lift; joint pain when lifting; joint cramping; carpal tunnel in both wrists; right shoulder pain; neck pain; anger; and confusion as reasons for his unemployment. Further, in September 2016, the Veteran reported interest in obtaining gainful employment, indicating that he believes he is capable of such. The Board notes the arguments of the Veteran’s representative in the May 2018 submission that a TDIU should be awarded because the Veteran communicated that he was unable to work, and VA acknowledged that the Veteran was unable to work. However, an award of TDIU is predicated on the inability to obtain and maintain gainful employment as a result of service-connected disabilities. Here, the Veteran to obtain and maintain employment has been attributed to his nonservice connected personality disorder and other nonservice connected physical disabilities, rather than his service connected anxiety disorder. This argument is therefore without merit. Therefore, based on the foregoing, the Board finds that, while the Veteran’s anxiety disorder NOS results in some impairment in occupational functioning, which is represented by his currently assigned 30 percent rating, such does not render him unable to secure or follow a substantially gainful occupation. Further, as noted previously, the Veteran is not service connected for any other disability. Therefore, the Board finds that the Veteran’s service-connected disabilities do not render him unable to secure and follow a substantially gainful occupation. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and a referral for extraschedular consideration for a TDIU is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Service Connection – PTSD The Veteran seeks service connection for PTSD. As noted above, the Veteran asserts he has PTSD as a result of stressors experienced during active service to include a murder of a cab driver, a head injury, and racism. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that §§ 1110 and 1131’s requirement of the existence of a present disability for VA compensation purposes cannot be considered arbitrary); see also McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA compensation is filed or during the pendency of that claim). Consequently, the evidence of record must show that the Veteran currently has the disability for which benefits are being claimed. In addition to the general principles governing service connection, to establish entitlement to service connection for PTSD the evidence must satisfy three basic elements. There must be: 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125 (a). In this regard, the Board notes that, for cases certified to the Board after August 4, 2014, as is the case here, the diagnosis of PTSD must be in accordance with the DSM-5. The Board notes service treatment records are negative for mental treatment, a diagnosis of an acquired psychiatric disorder in-service or functional impairments associated with psychiatric symptoms. VA treatment records do indicate the Veteran complained of, and was treated for, an acquired psychiatric disorder, that includes anxiety disorder NOS and paranoid personality disorder; however, they do not document a diagnosis of PTSD. In consideration of evidence of record, the Board finds no current diagnosis of PTSD is present. The Board notes a current disability is always required in order to establish service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). With regard to the claimed PTSD, there is not sufficient evidence to show that the Veteran has had PTSD during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board acknowledges the Court’s holding in Saunders but does not find a basis for determining that there is functional impairment related to a diagnosis of PTSD. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Veteran has been diagnosed with anxiety disorder NOS and paranoid personality disorder, and the Veteran has not related any functional impairments that are not attributable to these diagnoses. Moreover, the Veteran has not been diagnosed with PTSD in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). In this regard, in January 2013 and September 2019, the Veteran was afforded VA psychiatric examinations for his claimed PTSD. The VA examiners found that the Veteran’s symptoms did not meet the diagnostic criteria for PTSD. Specifically, the September 2019 VA examiner found that the Veteran’s symptoms did not meet the diagnostic criteria for PTSD under DSM-5 criteria. In addition, the Veteran has not alleged, and the record has not shown, manifestations of similar severity, frequency, and duration for the claimed PTSD as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 2020 U.S. App. Vet. Claims LEXIS 1609. The Board acknowledges the statements of the Veteran as to the existence and etiology of his PTSD, and acknowledges that the Veteran is competent to give evidence about what he experienced. For example, he is competent to discuss the fact that he experiences psychiatric symptoms. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). However, while the Veteran is competent to report his current symptoms, as a lay person he does not have the education, training, experience to diagnose or opine as to the etiology of the condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1377-78 (Fed. Cir. 2007). In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, supra. Therefore, as the evidence of record shows that the Veteran does not have a current diagnosis of PTSD, the Board concludes that service connection is not warranted, and no further discussion of the remaining elements is necessary. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) (“A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service.”); see also Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006) (finding that the absence of any one element will result in denial of service connection). Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for PTSD and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.