Citation Nr: 21077234 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 14-11 323 DATE: December 29, 2021 ORDER Entitlement to an initial increased rating in excess of 50 percent for post-traumatic stress disorder (PTSD) is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT Throughout the period on appeal, the most competent and probative evidence of record shows that the Veteran's service-connected PTSD manifested in no worse than occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for entitlement to an initial increased rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from April 1967 to April 1969. The Board notes that the Veteran had additional service from July 1969 to September 1974 that is considered disqualifying for VA purposes. Sadly, the Veteran died in May 2014 during the appeal. His surviving spouse (also referred to as the "appellant") has been substituted for purposes of continuing his appeal. These matters come before the Board of Veterans' Appeals (Board) from July 2012 and October 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran's surviving spouse appeared at a December 2015 hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. These matters have a lengthy procedural history that has been outlined in detail in prior Board decisions that are incorporated herein by reference. Most relevant to this decision, both claims were previously denied by the Board in a June 2018 decision. The appellant appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In response to a June 2019 Joint Motion for Partial Remand, the Court vacated the Board decision and remanded the Veteran's claims to the Board. Both claims were again denied in a September 2019 Board decision which the appellant also appealed to the Court. In September of 2020, the Court issued a Memorandum Decision in response to the appellant's appeal and the Court vacated and remanded the appellant's claims to the Board. The claims were subsequently remanded by the Board in April of 2021 and most recently in September of 2021. The case has now been returned to the Board for further appellate review. Entitlement to an initial increased rating in excess of 50 percent for PTSD is denied. The Appellant contends that the Veteran's PTSD warranted an initial rating in excess of 50 percent. Psychiatric disorders are rated pursuant to the criteria under 38 C.F.R. § 4.130, Diagnostic Code 9411. See General Rating Formula for Rating Mental Disorders (General Rating Formula). Relevant to the issue on appeal, under the General Rating Formula, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory, e.g., retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. The next higher and maximum 100 percent rating 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. Symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Id. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. Id. Following a thorough review of the evidence of record, the Board once again finds that the evidence is not found to support a higher evaluation for PTSD than the 50 percent rating currently assigned. The Board observes that notes from VA treatment records during throughout the period on appeal reflect that the Veteran largely continued to report symptoms that justify, at most, the 50 percent rating currently assigned. An August 2005 psychiatry note documented a diagnosis of "chronic PTSD" and self-reported symptoms were described as "inconsistent, e.g. saying he feels great" but then stating that he "feels depressed most of the time". He presented as a "causally dressed middle-aged man who seemed cheerful despite talking about things he said made him depressed". Further, there was "no evidence of hallucinations, delusions, or suicidal or homicidal ideation". While his insight and judgment were described as "poor", his "thoughts were logical and goal-directed". A November 2005 treatment note described the Veteran's mood as "moderately anxious and depressed". There was "no evidence of suicidal or homicidal ideation, hallucinations, or delusions". He had "been having increased nightmares" with "no dreams about Vietnam but has recurring thoughts about it every day". He stated that he was "irritable and cries a lot". See VA Treatment Records Received November 2005. In June 2006, the Veteran reported that his mood had been "stable" and that he "feels great overall". He denied any suicidal or homicidal ideation. See VA Treatment Records Received June 2006; see also VA Treatment Records Received January 2014. In August 2006, the Veteran reported "feeling calmer and not crying as much" and having "no suicidal or homicidal ideation, hallucinations, or delusions". His mood reportedly did "not seem labile". Id. A June 2011 psychiatry note indicated improved PTSD symptoms and the Veteran stated that he discontinued his medication and reported no nightmares. Id. In September 2011, the Veteran reported that he was doing well and felt "normal" besides having difficulty sleeping. Id. However, in December 2011, the Veteran stated that he "of course" had nightmares, anxiety, and became edgy because he had PTSD. Id. An August 2012 psychiatry note indicates that "on evaluation patient describes recurrent but manageable PTSD symptoms (intrusive thoughts about Vietnam, combat related nightmares, and night sweats)". It was noted that the Veteran was "wearing appropriate clothing" and "appears to practice good hygiene and displays no unusual characteristics/movements". He had good eye contact and was cooperative with "no disturbance of psychomotor activity". His impulse and judgment were "impaired" but also "intact". His impulse control was "intact" and there was no evidence of suicidal or homicidal ideation, perceptual disturbances, or delusions. See VA Treatment Records Received October 2013. Two months later, the Veteran reported some frustration and continued nightmares and reported that socially he prefers solitary activities such as walking his dog. He denied hypervigilance. Id. In November 2013, the Veteran once again denied suicidal or homicidal ideation. See VA Treatment Records Received January 2014. Here, numerous medical opinions are of record, all of which were provided by medical professionals who are presumed to have the training and expertise to opine on PTSD. When evaluating the evidence of record, the Board must assess the credibility and probative value of the evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). In February 2012, the Veteran underwent an initial VA PTSD examination. The examiner stated that the Veteran was currently diagnosed with PTSD, cannabis dependence with physiological dependence, and polysubstance dependence. The examiner stated that it is not possible to differentiate what symptoms are attributable to each diagnosis. The examiner stated that the Veteran's PTSD results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. It was also noted that the Veteran reported that after Vietnam he continued to have a good relationship with his wife of approximately 40 years, friends, and other family members. The Veteran reported that he had had a fair relationship with his son due to some relational difficulties. The examiner noted that the Veteran was experiencing depressed mood and difficulty in adapting to stressful circumstances, including work or a work like setting as a result of his PTSD. The examiner also noted symptoms of difficulty falling or staying asleep, irritability or outbursts of anger, and feelings of detachment. Pursuant to the Board's May 2016 remand, a medical opinion as to the severity of the Veteran's PTSD, as well as its effect on the Veteran's employability, particularly since the February 2012 VA examination until the Veteran's death in May 2014, was obtained in December 2016. After summarizing the Veteran's treatment records, the December 2016 examiner noted that "there is no medical evidence that Veteran's PTSD increased in severity following his 2012 Initial C&P Examination" and that his "PTSD symptoms remained stable, with continued symptoms that are described as 'recurrent but manageable' with psychotropic medications". Further, "no significant mental health concerns were noted on [the] most recent mental health records, suggesting that prior to his death in 2014, Veteran was coping effectively with PTSD symptoms and that they were causing minimal psychosocial impairment at that time". However, the Board acknowledges that the Court found the December 2016 VA examination report to be inadequate in its September 2020 Memorandum Decision. In addition to determining that the December 2016 VA medical professional apparently categorically limited her opinion to medical evidence and did not adequately consider the lay evidence, the Court also asserted that "the 2016 VA examiner commented negatively on appellant's December 2015 statement of her observations of the veteran's PTSD-related symptoms. Oddly, the examiner opined that the statement 'provided no specific details regarding symptoms or impairments associated with PTSD.' We don't see how that is the case given that appellant specifically described the veteran's symptoms and how they affected his life." In that regard, the Board recognizes as directed by the Court, the recent Court decision in Miller v. Wilkie ruling that when a VA examiner fails to address relevant lay evidence and the Board fails to find the Veteran [or appellant] not credible or not competent to offer that lay evidence, the proper remedy is for VA to obtain a new examination. See Miller v. Wilkie, 32 Vet.App. 249 (2020). The Board therefore remanded this claim in April of 2021 for a new opinion. Unfortunately, the VA opinion authored in June of 2021 in order to comply with the Board's April 2021 remand also lacked sufficient rationale as that examiner provided rationale that was nearly identical to the December 2016 VA examination report which the Court had previously asserted was inadequate. Therefore, the Board most recently remanded these claims in September of 2021 so that an additional VA opinion could be obtained. Initially addressing the Court directives, the October 2021 VA clinician noted that "all records including VBMS, JLV and CPRS were reviewed again. The remand was reviewed again along with vet's wife's lay testimony." Further, the VA clinician stated that, "I am a board certified psychiatrist (MD) performing C&P interviews for over 20 years. It is this examiner's opinion that the severity of the PTSD diagnosis was mild in this veteran with little to NO impact on social or occupational functioning. Objective record review proves this contention. Veteran is deceased since May 2014 but all mental health records were reviewed before 2014. The medical records consistently cite that the severity of this veteran's PTSD diagnosis was quite mild. There were NO psychiatric hospital stays or emergency room visits which would indicate that the severity of the condition would be moderate to severe. In fact veteran was on very few psychiatric medications over the years since he did not complain much about significant PTSD symptoms. Rather the medical records display chronic cannabis use disorder which can lead to certain mental health symptoms rather than true PTSD." In addition to pointing to several treatment-related notations, the VA clinician also stated that "furthermore [the] C&P exam from Feb 21, 2012 showed only mild symptoms of PTSD with no significant impact on social or occupational functioning. Veteran's death in May 2014 was a result of an accidental fall per [local] Medical examiner's office. It is important to note that none of the medical records documented any type of significant impairment on occupational functioning. He was able to interact well with supervisors and not miss work. He was able to interact appropriately with coworkers and followed instructions well. It should be noted that veteran's wife's opinions are considered subjective and biased and family members may be motivated to exaggerate the range and severity of mental symptoms (and disability) for secondary gain purposes. Medical records containing more objective and nonbiased documentation clearly does not support the contention that veteran had any occupational problems from PTSD diagnosis and he certainly did not have any progression of symptoms." The Board also notes that the Appellant submitted a private medical opinion in July of 2017 that was authored by an examiner who reached a different conclusion. The psychologist summarized the Veteran's and his surviving spouse's statements regarding the Veteran's PTSD in opining that "based on the medical records, the personal statements, and even some portions of the C&P PTSD exam, the Veteran fits the VA disability rating of 70 percent for PTSD". The examiner indicated with a bold "YES" the four symptoms suggested by the rating criteria for a 70 percent rating that the examiner opined the Veteran had exhibited. The Court has dictated that in assessing the probative weight of medical opinions and the value of reviewing the claims folder, claims file review, as it pertains to obtaining an overview of the claimant's medical history, is not a requirement for private medical opinions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Rather, the Court added, "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." The Board notes that while stating that records had been reviewed, this private examiner did not specify any documents to which he was referring in drawing a positive conclusion, nor did he provide further rationale regarding his conclusory statements. This examiner has drawn a conclusion, but there is insufficient supportive rationale and, significantly, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Instead of authoring an opinion with sound reasoning, it appears that this opinion is based at least in part on unsubstantiated assertions made by the appellant, a fact discussed in more detail below. The private examiner asserted, for example, that the Veteran's surviving spouse reported that the Veteran "was on Social Security Disability for PTSD". However, while the Veteran clearly received Social Security Administration (SSA) payments prior to his death, his receipt of these benefits was also clearly a result of the cumulative effects of several medical conditions including nonservice-connected hepatitis-C, cannabis dependence, right shoulder conditions, and status postclavicular fracture in addition to service-connected PTSD. See e.g. SSA-831 Disability Determination Received October 2016. Further, that determination, which considered the testimony of the Veteran himself, noted that "the evidence of record shows the claimant is symptomatic with post-traumatic stress disorder that imposes nonexertional mental limitations. These symptoms include intrusive memories, nightmares, night sweats, feelings of guilt, anger, fear, crying episodes and hypervigilance." As such, the SSA determination actually notes symptoms that were similar in nature and severity to those noted elsewhere in this decision and documented throughout the record. In addition, it reflects that the statement that the Veteran "was on Social Security Disability for PTSD" is not wholly accurate. A medical opinion predicated upon a history related by a veteran (or appellant) may not be refuted or disregard solely on that basis, but this fact may be considered in determining the probative value of the statement. Kowalski v. Nicholson, 19 Vet. App. 171, 170 (2005). Diagnoses or opinions which are based on a history provided by a veteran (or appellant) means that such conclusions "can be no better than the facts alleged by the appellant." Swann v. Brown, 5 Vet. App. 229, 233 (1993); see also Reonal v. Brown, 5 Vet. App. 458 (1993) (a medical "opinion based upon an inaccurate factual premise has no probative value"). While the private examiner clearly relied on assertions made by the appellant (one section explicitly states "from the Veteran's wife's notes"), it is unclear to what extent the examiner actually considered other evidence of record as, as stated above, the examiner did not reference any specific records in the rationale provided with his conclusions. Instead, the majority of the July 2017 private "opinion" entailed the private psychologist pointing to several sections of the February 2012 VA examination that he believed to be in error. However, multiple medical opinions have subsequently been obtained as to the severity of the Veteran's PTSD, which effectively cure any deficiencies that may be found in prior VA examination(s). Moreover, the Board reiterates that the assertions provided by the private examiner who provided the only favorable opinion of record among the numerous medical notations of record are negated by the objective evidence of record and appear to be based solely on purported lay statements. Again, while a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran, the Board may reject a medical opinion premised on an inaccurate factual basis. See Kowalski, 19 Vet. App. 171. In addition, the Board also notes that the treatment notations and statements made by the Veteran himself to providers, which are outlined extensively above, were for the purpose of treatment. Significantly, statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. See White v. Illinois, 502 U.S. 346, 356 (1992). Based on the foregoing, the Board finds that the private opinion is based, at least in part, on an inaccurate factual basis and is inconsistent with the totality of the evidence including with the Veteran's own statements. See Reonal, 5 Vet. App. 458, 461. And even more significantly, while proffering a conclusion, this examiner did not actually reference any specific symptoms, nor documentation of such symptoms, that would justify a higher rating nor otherwise provide a sufficient rationale. The Board therefore attaches minimal probative value to this opinion. The most competent and probative evidence of record weighs against a finding that a higher rating was warranted for the Veteran's PTSD. Again, even when authoring opinions since deemed inadequate, multiple VA examiners have made this determination, which is aligned with the Veteran's documented medical treatment history. Weighing the competing medical opinions, the Board is more persuaded by the adequate VA opinions of record, and particularly the October 2021 VA opinion which was authored by an examiner who explicitly considered the Veteran and his spouse's contentions, the claims file and the clinical medical evidence before providing a negative opinion. See Nieves-Rodriguez, 22 Vet. App. 295, 304 (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). That opinion is therefore afforded great probative weight, and the most probative weight in this case. The Board has also explicitly considered the lay statements of record once again, as most recently instructed by the Court, but has reached the same conclusion. Notably, the Court has held if a VA examiner explains whether the claimant's lay assertions are generally consistent or inconsistent with medical knowledge or evidence, the Board can weigh that when addressing credibility. See e.g. Miller, 32 Vet. App. 249, 259-60. The October 2021 VA clinician explicitly considered the appellant's lay assertions prior to concluding that they are inconsistent with the medical evidence of record. The Board must unfortunately agree. The Board reiterates that the statements made to the private examiner, for example, are not entirely factually accurate as outlined in detail above. As another example, despite the appellant recently asserting in August 2021 correspondence that the Veteran was suicidal, there is no evidence of this anywhere else in the claims file and he himself denied suicidal ideation on all occasions. Further, the Board observes that the Veteran's surviving spouse asserted at her December 2015 Board hearing to the inquiry of whether he'd left his former employer "because he didn't play well with others, is that the reason why?" that "Well not really because, uh, he just, like I said he didn't have very many friends and he just, uh, would rather, he was a loner." However, she attested at the same hearing to the inquiry of "he couldn't get along with the authority" and that "That's why, that's why he always worked by himself." The Board also acknowledges that the appellant has made the argument, both through herself and via her representative, that the Veteran was not open about the extent of his psychiatric symptoms in the context of conversing with VA examiners due to discomfort in conversing with them. Given the extent to which she claims the Veteran's psychiatric symptomology had worsened to prior to his death, it is unclear why there does not seem to be any objective evidence in the record supportive of these contentions. Further, the Board notes that treatment records indicate that the Veteran vocalized his complaints related to various conditions throughout the period on appeal, and it seems unlikely he would have willingly reported on other sensitive topics - including admitted substance abuse, sexual history, and prior arrests, for example - but exclude reporting symptoms of suicidal ideation. Moreover, the Board observes that the Veteran was fairly consistent in his recounting of his psychiatric symptoms and actually reported the same ones to SSA providers (representatives of an entirely different government agency and one that granted him a fully favorable outcome), which further negates any argument that he hid the truth from VA providers due to purportedly unpleasant interactions with them. While the Board makes no judgment in regard to the genuineness of the appellant's beliefs in this case, it is observed that the discrepancies between some of those asserted beliefs and the objective evidence that is easily verifiable (i.e. the SSA decision) unfortunately indicate that the appellant is not an entirely reliable historian. The Board is therefore unable to accept her uncorroborated account of a more severe version of the Veteran's claimed psychiatric symptomology when the Veteran himself denied having this symptomology and it is not documented anywhere else in the record. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995). The appellant's lay assertions in the present case are outweighed by the clinical evidence of record discussed in thorough detail above, which is at least at times inconsistent with the lay assertions regarding the extent of the Veteran's symptomology. The Federal Circuit has held that the Board can favor competent medical evidence over lay statements offered by the Veteran (or appellant), as long as the Board neither deems lay evidence categorically incompetent nor improperly requires a medical opinion as the sole way to prove an assertion. See King v. Shinseki, 700 F.3d 1339, 1344 (2012). Moreover, the Court has more recently concluded that the Board can discount lay evidence in its role as factfinder if it weighs the evidence, finds the clinical evidence more probative, and provides an explanation with supporting reasons or bases. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). As discussed above, the Board has accomplished this in the present case, as the lay assertions are unpersuasive in the present case due to the strong clinical evidence establishing that the severity of the Veteran's psychiatric condition was, at worst, aligned with the rating currently assigned. After reviewing the medical and lay evidence of record, the Board has determined that a rating in excess of 50 percent for the Veteran's PTSD is not warranted. The Board finds that, throughout the relevant rating period, the Veteran's service-connected PTSD manifestations were, at worst, no more severe than occupational and social impairment with reduced reliability and productivity. The Board assigns significant probative value to the highly probative medical evidence and clinical findings in the record, which noted the Veteran's specific reported symptoms. During this period, the Veteran reported symptoms consistent with his current 50 percent rating such as impaired judgment and disturbances of motivation and mood. However, the record indicates that the Veteran did not even experience many of the symptoms that are consistent with the 50 percent rating currently assigned, such as difficulty in understanding complex commands, memory loss, flattened affect, impaired abstract thinking, circumstantial, circumlocutory, or stereotyped speech, nor panic attacks more than once a week. The evidence of record is not indicative of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood such that would justify a 70 percent rating. There is no evidence of obsessive rituals which interfere with routine activities and while the Veteran continuously reported irritability and frustration, there is no indication of violence. At all times, the Veteran denied suicidal ideation, maintained his personal appearance and hygiene, and otherwise demonstrated that he had the ability to function independently, appropriately, and effectively. Throughout the medical record, the Veteran is noted as having normal conversation, interacting appropriately with providers, and at all times he had been appropriate in his appearance. The Board acknowledges that the Veteran reported a less than ideal relationship with his son, which is an arguable example of the "inability to establish and maintain effective relationships" symptom provided in the criteria for a 70 percent rating. However, the Board reiterates that the Veteran good relationships with numerous other family members, including a marriage that lasted more than four decades and ended with his death. Given all the other symptoms that are consistent with, at most, a 50 percent rating and not a 70 percent rating, the Board concludes that, overall, the Veteran's psychiatric symptomatology more closely coincides with the criteria for a 50 percent rating in terms of severity, frequency, and duration. Similarly, the Board has considered whether the Veteran's symptoms constitute a total occupational and social impairment which would justify the next higher and maximum 100 percent rating. However, the Veteran consistently denied having, and the record does not independently demonstrate that the Veteran had persistent delusions or hallucinations or any inclination toward hurting himself or others. The record also contains no evidence of grossly inappropriate behavior, nor any intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. In contrast, the Board reiterates that the Veteran presented with adequate dress and hygiene at all times. Further, there is no indication that the Veteran was ever disoriented to time or place, nor that he had ever experienced memory loss for names of close relatives, his own occupation, or his own name. Based on the foregoing, the Veteran's PTSD represents, at worst, an occupational and social impairment with reduced reliability and productivity and a 50 percent rating is appropriate. The Board has also considered the fact that it has been reported that the Veteran reportedly last worked in January 2005. See e.g. Private Medical Opinion Received July 2017. Similarly, the Board recognizes the January 2018 lay statement submitted by the Veteran's wife in which she asserts that "he struggled to hold down a job" and had "difficulty in adapting to stressful circumstances in work and work-like settings". The fact that the Veteran's service-connected PTSD results in occupational impairment has been considered by the Board. Such impairment is explicitly contemplated by the schedular criteria. Even if the Veteran was not working during the period at issue, that does not by itself define his level of impairment and does not by itself demonstrate that a rating in excess of 50 percent is warranted. Specifically, it does not, in and of itself, demonstrate that the Veteran had occupational and social impairment with deficiencies in most areas such as work. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In the above discussion, the Board detailed the factors constituting the Veteran's overall disability picture. The Board has coordinated the Veteran's demonstrated level of impairment with the rating criteria. See 38 C.F.R. § 4.21; see also Mauerhan, 16 Vet. App. 436. Although the record shows that the Veteran may not have worked since January 2005, it also shows that, overall, the Veteran's psychiatric symptomatology did not more closely approximate the level of severity contemplated by the criteria for ratings in excess of 50 percent. The Board remains sympathetic to the Veteran's contention of experiencing traumatic events while in-service, as well as to the appellant's loss of her husband. However, the Board once again emphasizes that adequate compensation for the Veteran's PTSD has been afforded during the entirety of the appeal. In so finding, consideration has been given as to the appropriateness of staged ratings; however, at no time during the relevant appeal period does the evidence support such an award. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Based on the foregoing, a disability rating greater than 50 percent is not warranted. The preponderance of the evidence is against the claim and there is no doubt to be resolved. See 38 C.F.R. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Entitlement to a TDIU is remanded. Unfortunately, the Board cannot make a fully-informed decision in regard to the TDIU issue until additional development is undertaken. More specifically, it is unclear from the record exactly when the Veteran ceased full-time employment, why he stopped working, and whether his work beforehand constituted marginal employment. The Veteran asserted on his September 2012 VA Form 21-8940 that he last worked self-employed as a house painter due solely to his PTSD but that this ceased in December 2004. However, there appears to be substantial evidence that conflicts with this. A January 2005 VA treatment notation indicates that the Veteran reported that he "works as a housepainter and does other maintenance work when he can". A similar notation was made in August of 2005. A notation from a March 2005 SSA disability report notes that the Veteran reported he had ceased employment on "6/1/1995" and "stopped due to pain all over my body". However, he concurrently stated that he "cannot work due to pain of [non-service-connected] stab wounds" and listed the date that he became unable to work as "9/16/2004". A March 2006 VA treatment notation indicates that the Veteran stated that "today I was working in an old house, & a hypodermic needle came out of the wall I was tearing into and pierced my skin in my right elbow". The Veteran's favorable May 2007 SSA determination indicates that "the claimant testified that he is disabled and cannot work because of pain in his liver, hepatitis C, post-traumatic stress disorder symptoms, right shoulder pain, swelling of his knees when walking on uneven ground, breathing difficulties, chronic diarrhea and abdominal pain related to multiple stab wounds, headaches, dizziness, problems with his equilibrium, and a lump in the top of his throat." See SSA-831 Disability Determination Received October 2016. It was determined based on the collective impact of several conditions that he was "incapable of performing his past medium exertional level work [painting in construction]". The Board observes that the Veteran was not service-connected for anything other than a psychiatric condition at any point. In March of 2012, he reported being "retired from work". However, the Board notes that a May 2014 medical examiner's report authored after the Veteran's death concludes that, "it is our opinion that [the Veteran], a 65 year old male, died a result of complications of injuries sustained in a fall from height. The decedent was reportedly working on a ladder or rooftop prior to being found on the ground unresponsive." Based on the foregoing, the Board finds that the appellant should be afforded the opportunity to present any additional evidence that could help clarify when the Veteran reportedly ceased gainful employment. For example, December 2021 correspondence from the appellant's representative indicates that she "reports that [the Veteran] found his job too stressful and left it to begin painting on his own." Information regarding this employer is unfortunately not yet of record. As the Veteran last submitted a VA Form 21-8940 in September of 2012 and as the one submitted at that time did not contain the entirety of the Veteran's employment information, the appellant should be asked to complete an updated one on remand. In addition, given the disparity in the evidence of record regarding the Veteran's employment information and the medical condition(s) that reportedly caused him to cease working, each identified former employer should be asked to complete a VA Form 21-4192 (Request for Employment Information in connection with Claim for Disability Benefits). Further, an earnings statement should be obtained from SSA and associated with the claims file in order to clarify the Veteran's income for the periods that he did work prior to his death. The matters are REMANDED for the following actions: 1. Contact SSA and request the Veteran's earning statements from 2004 through 2014. If SSA responds that it cannot provide earnings statements to VA without the appellant's approval, undertake the necessary actions to obtain any documentation needed from the appellant to enable VA to obtain a copy of the Veteran's SSA earnings statements. 2. Request that the appellant complete and return an updated VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). She should additionally be asked to submit any additional evidence she has that supports her contentions, which should include a request to provide a detailed statement as to the Veteran's employment history since service along with his duties at those places of employment, whether he was working in a protected environment and/or whether he earned more than the poverty level, whether he continued to be employed until he passed away, the approximate date(s) he stopped working full and/or part time, and how she believes that his service-connected disability alone prevented him from obtaining and maintaining substantial gainful employment in both fields that are sedentary and physically demanding. The request should also notify the appellant that the claim for a TDIU can be denied if she fails to cooperate with the prosecution of the claim by providing the VA Form 21-8940 and any other relevant documentation. 3. Ask any of the Veteran's former employers that are identified on remand to complete a Request for Employment Information in Connection with Claim for Disability Benefits, VA Form 21-4192. Any employer identified on the updated VA Form 21-8940 is specifically asked to: (a) list all dates of the Veteran's employment, the positions worked, AND rates of pay/salary information for those respective periods; and (b) clarify why the Veteran's employment ended. 4. Thereafter, readjudicate the claim. If the benefits sought on appeal remain denied, issue a supplemental statement of the case to the appellant and her representative. Then return the appeal to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Smith, 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.