Citation Nr: 21013253 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 13-30 133 DATE: March 9, 2021 ORDER Prior to September 22, 2013, an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) is denied. For the period from September 23, 2013 to September 4, 2019, an evaluation in excess of 50 percent for PTSD is denied. For the period from July 30, 2010, to September 22, 2013, a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. As of September 4, a TDIU is granted, subject to the laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. Prior to September 22, 2013, the evidence shows that the Veteran’s PTSD has been productive of symptoms that include depression, and sleep impairment, but the weight of the evidence is against the conclusion that the psychiatric symptoms have been of such pervasiveness or severity as to cause occupational and social impairment with reduced reliability and productivity or worse. 2. For the period from September 23, 2013 to September 4, 2019, the Veteran’s PTSD is not shown to have resulted in severe impairment or occupational and social impairment with deficiencies in most areas. 3. Prior to September 22, 2013, the Veteran’s service-connected disabilities did not render him unable to secure and follow a substantially gainful occupation. 4. As of September 4, 2019, the Veteran’s service-connected disabilities rendered him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. Prior to September 22, 2013, the criteria for an evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 5107, 1155; 38 C.F.R. §§ 3.102, 4.7, 4.10, 4.130, Diagnostic Code 9411. 2. For the period from September 23, 2013, to September 4, 2019, the criteria for an evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 5107, 1155; 38 C.F.R. §§ 3.102, 4.7, 4.10, 4.130, Diagnostic Code 9411. 3. For the period from July 30, 2010 to September 22, 2013, the criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.16. 4. As of September 4, 2019, the criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In August 2011, the Agency of Original Jurisdiction (AOJ) granted service connection for PTSD, evaluated as 30 percent disabling, with an effective date of July 30, 2010. The Veteran appealed the issue of entitlement to an initial evaluation in excess of 30 percent. In March 2016, the AOJ granted the claim to the extent that it assigned a 50 percent evaluation with an effective date of September 22, 2013. In May 2018, the Board of Veterans’ Appeals (Board) denied an increased evaluation for PTSD, evaluated as 30 percent prior to September 22, 2013, and as 50 percent disabling thereafter. The Veteran appealed the Board’s May 2018 decision to the U.S. Court of Appeals for Veterans Claims (Court). In January 2019, while his case was pending at the Court, the VA’s Office of General Counsel and the Veteran’s representative filed a Joint Motion requesting that the Court vacate the Board’s May 2018 decision. That same month, the Court issued an Order vacating the May 2018 Board decision and remanding the case for compliance with a Joint Motion for Remand. In October 2019, the Board granted the claim to the extent that it assigned a 70 percent evaluation for PTSD effective September 4, 2019. The Board also granted entitlement to a TDIU for the period from September 22, 2013, to September 4, 2019; the Board dismissed the TDIU claim for the period dating from September 4, 2019. The Veteran appealed the October 2019 Board decision to the Court. In September 2020, while his case was pending at the Court, the VA’s Office of General Counsel and the Veteran’s representative filed a Joint Motion requesting that the Court vacate the Board’s October 2019 decision. That same month, the Court issued an Order vacating the October 2019 Board decision and remanding the case for compliance with a Joint Motion for Remand (JMR). Such JMR makes it clear that the Board’s favorable aspects of its October 2019 decision as to the issues on appeal remain in effect and that the issue of entitlement to a rating in excess of 70 percent as of September 4, 2019, was dismissed. Medrano v. Nicholson, 21 Vet. App. 165, 170 (2007). 1. Entitlement to an increased initial evaluation for PTSD. With regard to the history of the disability in issue, the Veteran is shown to have served in Vietnam with the Marine Corps. His awards include the Combat Action Ribbon. Following separation from service, other than some marriage counseling, he is first shown to have been treated for complaints of psychiatric symptoms in 2010. The Veteran’s PTSD has been evaluated from 30 percent to 50 percent disabling during the time periods at issue under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, under the general rating formula for mental disorders, which became effective prior to the Veteran’s claim for service connection. A 30 percent rating is assigned when a veteran’s psychiatric disability causes 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, or mild memory loss (such as forgetting names, directions, recent events). Id. Under DC 9411, a 50 percent rating is warranted when a psychiatric disability causes 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. Under DC 9411, a 70 percent rating is warranted where an acquired psychiatric disability causes 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 ideations; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. That portion of VA’s Schedule for Rating Disabilities (“the Schedule”) that addresses service-connected psychiatric disabilities was based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) IV prior to a change effective August 4, 2014. 38 C.F.R. § 4.130. The regulation has been changed to reflect the current DSM, the DSM-V. As this appeal was certified to the Board in November 2013, prior to the effective date for this change, DSM-5 is not applicable to this claim. See 70 Fed. Reg. 45,093-94 (Aug. 4, 2014). As such, the use of global assessment of functioning scores is warranted. Golden v. Shulkin, 29 Vet. App. 221 (2018). In this regard, reports of psychiatric examination and treatment frequently include a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF scale includes scores ranging between zero and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner’s assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). See Quick Reference to the Diagnostic Criteria from DSM-IV at 47 (American Psychiatric Association 1994) ("QRDC DSM-IV"). Prior to September 22, 2013. Statements from the Veteran’s former spouse, B.C., received in October 2011 and October 2013 show that she states the following: They were married in 1975 and divorced in 1987. The Veteran was a heavy beer drinker when they met in 1974. He had a volatile relationship with his ex-wife. The Veteran’s first wife had written that she was scared of him and his behaviors and that she could not live with him anymore. The Veteran had nightmares throughout their marriage and trouble sleeping. He displayed few emotions other than anger. His drinking escalated, with blackouts and some physical abuse. He destroyed property in the house, and he could not handle noise, confusion, children, disorder, or marital stress. They have remained friends following their divorce. In an October 2013 statement, she states that she has been with the Veteran for 28 years. In the September 22, 2013, statement, she stated that the Veteran was unable to work due to his service-connected coronary artery disease, diabetes, right shoulder, and chronic enteritis. Prior to his most recent job at an automotive dealership ending (and indicating that this happened after the manufacturer stopped making the line of cars he was selling), he started having panic attacks at the thought of what he would do to provide for his family. His isolating behavior was so severe that few of her acquaintances had ever met the Veteran. According to her, he had panic attacks in crowds. A VA PTSD examination report dated in February 2011 notes the following: The Veteran received outpatient treatment beginning in 2010. He is not currently on medication for his symptoms. Therapy had resulted in a good effect on his symptoms. He has been married three times. He has a daughter from his first marriage, which lasted seven years, and three children from his second marriage, which lasted 12 years. His second marriage ended because he was an alcoholic and he was verbally abusive. He has now been married for 21 years. He has a stepson. He reported having good relations with all of his children and his stepson. He goes to family gatherings for holidays and he enjoys having people come to his home. He used to ride motorcycles, but he stopped in 2002, after driving around the country for two to three months. He does yard work and reads novels. He owns a cabin in another state. He last worked in March 2010 as a sales manager for an automobile dealership. He was ready to retire, and his health problems increased. He has multiple health conditions that prevent work, to include gastroesophageal reflux disease, hypertension, and diabetes. His work history includes work in auto sales for 13 years and work in industrial equipment sales for 11 years. He has also done construction, carpentry, and masonry. He was hospitalized by his employer in the 1980s because of his drinking, and he received outpatient treatment for alcohol abuse. He stays active at home with his ADLs (activities of daily living). On examination, he was clean and neatly groomed. Affect was appropriate. Mood was good. Attention was intact. He was oriented to person, time, and place. Thought content and thought process were unremarkable. There was/were no delusions, hallucinations, inappropriate behavior, obsessive or ritualistic behavior, panic attacks, episodes of violence, or suicidal or homicidal thoughts. Recent, remote, and immediate memory were normal. With regard to insight, he understood that he has a problem. He was noted to have sleep impairment, typically retiring for sleep around 10 or 11pm, and rising and dressing between 3 and 4am. He drinks six cocktails a day to help sleep. He does not have clinically significant distress or impairment in social, occupational, or other important areas of functioning. He has chronic symptoms, with the frequency of recollections, memories, and intrusive thoughts have decreased over time, occurring “maybe once a week,” and they are mild to moderate, with a duration in minutes. The frequency, severity, and duration of his symptoms have decreased over the years. He is being taught coping skills. He avoids others and drinks when he is stressed. The Axis I diagnoses were PTSD and alcohol dependence. The Axis V diagnosis was a GAF score of 55. The changes in his functional status and quality of life following his exposure to trauma affected his performance in employment and his social and interpersonal relationships. His symptoms are productive of an occasional decrease in work efficiency and there are intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning (routine self-care, and conversations normal). He has continued alcohol abuse limits outside social activity and driving. The Veteran is comfortable remaining at home while his wife works. He enjoys entertaining in his home. A VA heart disability benefits questionnaire (DBQ) dated in April 2011 shows that the Veteran reported that he was not retired and not currently employed. He reported that he had been unemployed for about one to two years and that the reason he was unemployed was because he was unable to find work. A VA joints DBQ dated in April 2011 shows that the Veteran reported that he was not employed and that he was not retired. It was noted that he stopped working as a builder about a year before due to his shoulder condition, with another notation that he had stopped working due to progressive, intermittent right shoulder pain, limitation of motion, and guarding. VA progress notes dated between August 2010 and 2011 note the following: In August 2010, the Veteran’s medical history includes PTSD and a reported 40-year history of depression, with no previous treatment. The Veteran reported having some trouble concentrating for several days, and having daily trouble sleeping, and feeling down, depressed or hopeless half of his days. A depression screen was positive. He denied thoughts that he would be better off dead or of hurting himself in some way, or of feeling bad about himself. In October 2010, he complained of symptoms that included anxiety, sleep problems, irritability, difficulty concentrating, hypervigilance, an exaggerated startle response, recurrent intrusive thoughts and distressing dreams, not wanting to be around people, and a lower tolerance for things. He denied taking, or ever having taken, any psychotropic medications. He participated in psychotherapy about 35 years before, once or twice, for marital problems. He has never attempted suicide or been hospitalized for mental health problems. He has about six drinks a day. He was referred for ADATP (VA Alcohol and Drug Abuse Treatment Program). He reported having a supportive wife and good relationships with his family. He doesn’t have a lot of friends, but he has some acquaintances. He stays in touch and has good relationships with his siblings. He does not have suicidal thoughts. On examination, he was oriented times three. Speech had a normal rate and rhythm. There was no unusual thought content. Thought process and associations were normal and coherent. Insight and judgment were fair. There were no hallucinations or perceptual disturbances. Memory was intact. He denied thoughts that he would be better off dead or of hurting himself in some way, or of feeling bad about himself. The Axis I diagnosis was PTSD. The Axis V diagnosis was a GAF score of 49. In December 2010, he reported hypervigilance, hyperarousal, and poor sleep. He was noted to be anxious. He denied suicidal thoughts. He was alert and oriented times four. He was afforded a GAF score of 45. In 2011, he was noted to have had five to six drinks a day for several years. He was also noted to be unemployed. Reports dated in March and August of 2011 show that the Veteran reported that he was doing “ok” and “doing well”, respectively. The August 2011 report shows that the Veteran reported that he spends weeks and months on his farm (100 acres of land with a cabin that he built in another state). He goes there and he is able to work the land until he is exhausted and can go to sleep. His wife remains in the area, but they visit on and off. The Veteran reported that things were going better since he officially retired. He isolates to find relief, but he is also realizing that he needs social interaction, “so this is a double-edge sword.” He felt guilty over his heavy drinking during his children’s upbringing, of which he had little memory. He is close to his ex-wife. He met with his daughter about two weeks’ before, on his farm. The findings were consistent with those noted in October 2010. See also December 2011 report (same). The GAF scores in 2011 were 50 (March), 58 and 59 (August), and 58 (December). A report from M.C., M.D., received in December 2020 shows that he states that by 2010, the Veteran could no longer function in an occupational environment and that he was struggling with even the basic interactions in his home life, including even those with his wife, who was dedicated to his well-being. The Veteran’s symptoms of PTSD had become overwhelming by 2010 and were no longer manageable by the Veteran. He withdrew to his home and he became reclusive, refusing to engage with any other individuals and no longer leaving home. As of 2010, the Veteran began an insidious process when he discontinued working entirely as his PTSD became the predominant component of his day-to-day life. By March 2010, he was completely unemployable based off his PTSD, and his mental illness had become completely disabled both socially and occupationally. Even after the Veteran discontinued the vast majority of his alcohol intake and retired, things did not improve behaviorally or symptomatically. He became even more reclusive and less capable of articulating his feelings, emotions, and thoughts regarding the Republic of Vietnam. This is representative of extraordinarily severe mental illness preventing the Veteran from any chance of even a partial remission in his symptomatology. An application for increased compensation base on unemployability (VA Form 21-8940), received in October 2011, shows that the Veteran reported that he had four years of high school. He reported working 60 hours a week for an automobile dealer as a general manager between September 2003 and March 2009. He indicated that he left his job due to disability. He stated, “My doctor has indicated to me that I should not attempt to go back to work. It is not if but when I will have another heart attack.” Subsequently received VA Forms 21-8940 are discussed infra. The Board finds that an initial evaluation in excess of 30 percent is not warranted for the Veteran’s PTSD. The Veteran’s symptoms are not sufficiently severe to have resulted in occupational and social impairment with reduced reliability and productivity. The totality of the evidence shows that the Veteran’s PTSD more closely resembles the criteria for not more than a 30 percent evaluation. The Veteran has reported symptoms that include anxiety, sleep problems, irritability, difficulty concentrating, hypervigilance, an exaggerated startle response, recurrent intrusive thoughts and distressing dreams, not wanting to be around people, and a lower tolerance for things. He is not shown to have taken psychotropic medications during the time period in issue. There is no history of hospitalization for psychiatric symptoms. He has generally reported having good relationships with his family, and that while he does not have a lot of friends, he has some acquaintances. The findings tend to show that he was oriented, with normal speech, and normal thought content and thought process and associations. Insight and judgment were fair. Memory was intact. There is no evidence of suicidal or homicidal thoughts, or psychotic symptoms. With regard to his psychiatric symptoms, the Veteran’s GAF scores were 45, 49, 50, 58, and 59. This indicates moderate to serious symptoms. With regard to the presence of severe symptomatology, GAF scores are not dispositive of the level of impairment cause by such illness and they are to be considered in light of all of the evidence of record. Brambley v. Principi, 17 Vet. App. 20, 26 (2003). The February 2011 VA examination report shows that the examiner concluded that the Veteran’s symptoms were productive of an occasional decrease in work efficiency and there are intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning (routine self-care, and conversations normal). This most closely corresponds to no more than a 30 percent evaluation under the General Rating Formula. See 38 C.F.R. § 4.130. The Veteran did not receive psychiatric treatment after December 2011, and the findings of record do not show that the criteria for an evaluation in excess of 30 percent have been met. In summary, there is insufficient evidence of such symptoms as flattened affect; irregular speech; difficulty in understanding complex commands; impairment of short- and long-term memory; and impaired abstract thinking, nor are other psychiatric symptoms shown to have resulted in the required level of impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed.Cir. 2013). Given the foregoing, the Board finds that the Veteran’s symptoms are not of such severity to approximate, or more nearly approximate, the criteria for a 50 percent rating, and that the findings do not support a conclusion that the Veteran’s symptoms are productive of a “similar severity, frequency, and duration” as those required for a 50 percent rating. See 38 C.F.R. § 4.7; Vazquez-Claudio. In reaching this decision, the Board has considered the September 2020 JMR, which states that the Board’s October 2019 decision failed to consider the Veteran’s “reported social isolation,” citing Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990); 38 C.F.R. § 4.130, DC 9411. The JMR noted that, per VA progress notes dated in between January 2011 and April 2013, the Veteran had reported that he would isolate from others and avoided activities and situations that reminded him of stressful events; that he had a loss of interest in activities; that he spent most of the holiday season alone in his cabin; that he spent most of his life avoiding through work, isolation, and alcohol; that he had spent a lot of time, weeks, and months at “the farm,” and that he “isolates to find relief.” The JMR also found the Board did not explain “why any acknowledgment of needing social interaction reflected that he was capable of such social interaction given his reports of self-isolation.” While there is some evidence of the criteria required for a 50 percent rating, specifically, evidence that the Veteran has difficulty in establishing and maintaining effective work and social relationships, to include as due to social avoidance, the Board notes that under 38 C.F.R. § 4.126(b), when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. In this case, there is evidence indicates that the Veteran worked full-time, up to 60 hours a week, until March 2010. See February 2011 VA PTSD examination report; VA Form 21-8940, received in September 2019. To the extent that the Veteran asserts that he has been unable to work since 2010 due to PTSD, the record shows that he has made significantly contradictory statements as to the reason for his unemployment. See e.g., April 2011 VA infectious, immune and nutritional disabilities examination report DBQ (in which the Veteran reported that he was not retired and not currently employed, and that the reason he was unemployed was because he was unable to find work); April 2011 diabetes examination report (same); VA Form 21-8940, received in October 2011 (showing that the Veteran reported that his employer closed down in March 2009, that he had unsuccessfully applied for work at two other dealerships, and that his doctor had told him he should not go back to work due to heart symptoms); statement from the Veteran’s former spouse, B.C., received in October 2013 (indicating that he left this position because the Veteran’s employer stopped making the line of cars being sold by his employer, and that the Veteran is unable to work due to his service-connected coronary artery disease, diabetes, right shoulder, and chronic enteritis). Accordingly, his testimony has been afforded reduced probative value. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The medical evidence has been discussed, to include a February 2011 VA PTSD examination report which notes that the Veteran has multiple health conditions that prevent work, to include gastroesophageal reflux disease, hypertension, and diabetes. The most probative evidence indicates that the Veteran’s employer shut down in 2010 and that this was followed by his voluntary retirement in about mid-2011. Here, the Board finds such evidence is insufficient to show that he met the criteria for an evaluation in excess of 30 percent, even considering his symptoms associated with social isolation and social avoidance. The aforementioned findings do not show that the criteria for an evaluation in excess of 30 percent have been met prior to September 22, 2013. Accordingly, the claim is denied. From September 22, 2013, to September 4, 2019. The JMR states the following: A remand is warranted because the Board failed to ensure compliance with the January 2019 JMR. That JMR shows that the parties agreed that the Board had failed to adequately address occupational impairment. The JMR states that it remains unclear why occupational ability prior to 2010 is relevant to occupational ability in 2013 and later, the parties again agree that remand is required for the Board to explain why the Board found probative [the] Appellant’s description of his occupational ability prior to his 2010 retirement to his disability rating from September 2013 and to ensure substantial compliance with the January 2019 JMR. VA progress notes show that in July 2015, the Veteran reported having insomnia. He reported drinking monthly or less, with one or two drinks a day in the past year, and six or more drinks on one occasion less than monthly. In January 2016, he was noted to be stable to being transitioned from mental health specialty care to the primary care service, and not to be on psychotropic medication. A VA PTSD DBQ dated in February 2016 shows that the Veteran reported that his symptoms have increased in both their frequency and intensity since his last evaluation. He said that he had sold cars until 2010, and that when he was working he was good at his job and he was able to focus on the job at hand. He began counseling at the VA in about 2010, but he was never prescribed medication and he stop attending counseling after a few years. He continues to drink at night to aid in sleeping, but he does not drink to excess. He is prescribed Trazadone which he takes as needed. His symptoms were noted to include depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, panic attacks that occur weekly or less often, and difficulty in establishing and maintaining effective work and social relationships. On examination, he was groomed and appropriately dressed. Speech was clear and coherent. Attitude was cooperative and attentive. Affect was appropriate and mood was depressed. He was oriented times three. Testing was noted to show an intense mistrust of others that is combined with strong withdrawal tendencies and an inability to constrain persistent depressive feelings. The Veteran attempts to avoid emotional experiences and to suppress events that may evoke disturbing memories and feelings. These defensive efforts often preclude rewarding social experiences, and together with his affective indifference, occasional bizarreness, and withdrawal behavior, may provoke others to view him as peculiar and disconnected. Behavioral eccentricities, dissociative thinking, and depersonalization anxieties may also be occasionally evident. There was withdrawal behavior and occasional dissociative and magical thinking that further alienates others. The diagnosis was PTSD. The examiner indicated that the Veteran’s symptoms were productive of 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. VA progress notes indicate that between 2015 and 2019, the Veteran complained of such symptoms as insomnia and nightmares. However, he did not receive any treatment for psychiatric symptoms. In about January 2016, his medications briefly included Trazodone for sleep, with no indication of medication for psychotropic medications prior to this, or thereafter. Reports, dated in 2017, note that he has been married for 30 years, and that he retired eight years’ before. He denied having anxiety or depression. Overall, it was repeatedly noted that the Veteran reported that he worked on a farm, with notations that he works out and that he is active. The findings show that the Veteran was alert and oriented times three. He was not considered a danger to self or others. He denied having thoughts about killing or harming himself or others. He was not gravely disabled due to a mental disorder. His behavior does not indicate that he lacks the cognitive ability (either permanently or temporarily) to make appropriate decisions. Within the past 30 days, the Veteran had not attempted suicide or engaged in any gesture or action that could be thought of as self-directed violence. Within the past 12 months, the Veteran had not attempted suicide or engaged in any gesture or action that could be thought of as self-directed violence. He was noted to be ready to learn, with no barriers to learning identified, and to have complete understanding. Depression screens were negative. The Veteran’s symptoms have been noted to include depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, panic attacks that occur weekly or less often, and difficulty in establishing and maintaining effective work and social relationships. He was not regularly treated for his symptoms during the time period in issue. The only detailed findings are found in the February 2016 VA PTSD DBQ, which showed that he was groomed and appropriately dressed. Speech was clear and coherent. Attitude was cooperative and attentive. Affect was appropriate and mood was depressed. He was oriented times three. Overall, there is little or no evidence of suicidal ideation, obsessional rituals, speech intermittently illogical, obscure, or irrelevant, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, spatial disorientation, neglect of personal appearance and hygiene, or an inability to establish and maintain effective relationships. The February 2016 VA examiner concluded that the Veteran’s symptoms were productive of 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. This most closely corresponds to no more than a 30 percent evaluation under the General Rating Formula. 38 C.F.R. § 4.130. In summary, the evidence is insufficient to show that the Veteran has such symptoms as suicidal ideation with plan or intent, obsessional rituals, defects in speech, near-continuous panic or depression which affect his ability to function independently, appropriately, and effectively; impaired impulse control (other than as noted), spatial disorientation, neglect of personal appearance and hygiene, or difficulty in adapting to stressful circumstances, nor are there other psychiatric symptoms shown to have resulted in such impairment, such that a 70 percent evaluation is warranted. See 38 C.F.R. § 4.130; Vazquez-Claudio. Accordingly, an evaluation in excess of 50 percent is not warranted. For the entire time period in issue, the Board has considered Dr. M.C.’s September 2020 report. This report shows that that Dr. M.C. states that the Veteran has become more socially isolated and has removed himself from social interactions. The Veteran has limited social interactions with his wife and grandchildren, but when they are not around, he becomes reclusive and removed from society. Dr. M.C. acknowledged that the Veteran has not had formal treatment for psychiatric symptoms since 2011, but he essentially attributed this to the Veteran’s “being loath to discuss any aspect of his service.” Dr. M.C. stated that the Veteran lacks the cognitive ability to work and concluded that the Veteran has severe, pervasive, and intractable PTSD. Dr. M.C. primarily cites to findings in the medical evidence dated between August 2010 and December 2011. He acknowledged that the Veteran did not receive psychiatric treatment after 2011. The Board notes that there are some relevant ancillary findings in non-psychiatric treatment reports dated after 2011 (apart from the February 2016 VA examination report). The relevant findings do not show that the criteria for a 70 percent rating or more have been met, and they are significantly inconsistent with Dr. M.C.’s conclusion that the Veteran was unemployable due to PTSD as of March 2010. See e.g., findings in VA progress notes of moderate depression, with no homicidal or suicidal ideation. Dr. M.C. appears to have based his opinion, in large part, upon the Veteran’s self-reported history. However, the evidence of record dated in 2011 (discussed supra) shows that the Veteran was noted to be unable to work due to physical impairments. He attributed his unemployment to being unable to find work, to his heart condition, or due to his right shoulder condition. See also Veteran’s spouse’s statement, received in October 2013; February 2016 VA PTSD DBQ (noting that the Veteran reported that he worked until 2010, and when he was working he was good at his job and was able to focus on the job at hand). Dr. M.C.’s conclusion is also significantly inconsistent with, and is not corroborated by, the weight of the contemporaneous evidence of record, which does not indicate that his psychiatric symptoms were of such severity so as to preclude employment. Therefore, the Board has afforded the contemporaneous findings more probative value. See Boggs v. West, 11 Vet. App. 334, 344 (1998). This report is insufficiently probative to warrant a grant of the claim. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). 2. Entitlement to a TDIU from July 30, 2010, to September 22, 2013, and as of September 4, 2019. The Veteran asserts that he is entitled to a TDIU for the period from July 30, 2010, to September 22, 2013, and as of September 4, 2019. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person 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, the disability shall be ratable at 60 percent or more. If there are two or more such 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). If the schedular rating is less than 100 percent, the issue of unemployability must be determined without regard to the advancing age of the veteran. 38 C.F.R. §§ 3.341(a), 4.19. Factors to be considered are the veteran’s education, employment history and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). Being unable to maintain substantially gainful employment is not the same as being 100 percent disabled. “While the term ‘substantially gainful occupation’ may not set a clear numerical standard for determining TDIU, it does indicate an amount less than 100 percent.” Roberson v. Principi, 251 F.3d 1378 (Fed Cir. 2001). In determining entitlement to a TDIU, the central inquiry is whether the Veteran’s service-connected disabilities alone are of sufficient severity to cause unemployability, without regard to advancing age or disabilities for which service connection has not been established. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993); 38 C.F.R. §§ 3.341(a), 4.16(a). Marginal employment, defined as an amount of earned annual income that does not exceed the poverty threshold determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Substantially gainful employment is work that is more than marginal, which permits the individual to earn a “living wage.” See Moore v. Derwinski, 1 Vet. App. 356 (1991). In reaching a determination of TDIU, it is necessary that the record reflect some factor which takes his case outside the norm with respect to a similar level of disability under the rating schedule. 38 C.F.R. §§ 4.1, 4.15; Van Hoose, 4 Vet. App. 361 (1993). The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether or not the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Beaty v. Brown, 6 Vet. App. 532, 538 (1994). Service connection is currently in effect for: PTSD, evaluated as 30 percent disabling from July 30, 2010 to September 21, 2013, as 50 percent disabling from September 22, 2013, to September 3, 2019, and as 70 percent disabling as of September 4, 2019; coronary artery disease, evaluated as 60 percent disabling as of July 30, 2010; diabetes mellitus, type 2, evaluated as 20 percent disabling as of July 9, 2010; tinnitus, evaluated as 10 percent disabling as of July 30, 2010; chronic enteritis, evaluated as 10 percent disabling as of July 30, 2010; residual right shoulder dislocation, evaluated as noncompensable as of July 30, 2010; and bilateral hearing loss, evaluated as noncompensable as of July 30, 2010. The Veteran’s combined evaluation is 20 percent as of July 9, 2010, 80 percent as of July 30, 2010, and 90 percent as of September 22, 2013. A TDIU is currently in effect from September 22, 2013, to September 4, 2019. From July 30, 2010, to September 22, 2013. The September 2020 JMR shows the following: It was agreed that remand is required because the Board erred in failing to adjudicate whether the Veteran is entitled to TDIU for the period from July 30, 2010 to September 22, 2013. Citing 38 C.F.R. § 4.16; Rice; September 2019 report from Dr. M.C. The Veteran meets the schedular criteria for TDIU based upon two or more service-connected disabilities. 38 C.F.R. § 4.16(a). The evidence shows that the Veteran has psychiatric symptoms that included depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, panic attacks that occur weekly or less often, and difficulty in establishing and maintaining effective work and social relationships. It appears that the Veteran voluntarily retired in mid-2011. The Veteran is not shown to have received treatment for psychiatric symptoms after 2011, nor is he shown to have required medication for his psychiatric symptoms. The February 2011 VA examination report shows that a VA examiner concluded that his psychiatric symptoms were productive of 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. There is no competent and probative opinion of record to show that he was unemployable due to his service-connected psychiatric symptoms. Given the foregoing, the Board finds that the evidence of record is insufficient to show that the Veteran was unable to secure or follow a substantially gainful occupation because of his service-connected PTSD for the period from July 30, 2010, to September 22, 2013, and, therefore, the claim is denied. As of September 4, 2019. In its September 2019 decision, the Board stated that the grant of the Veteran’s TDIU is not predicated on a single disability but is predicated on multiple service-connected disabilities. Specifically, the grant of entitlement to TDIU was based largely in part on his diabetes, ischemic heart disease, and PTSD. Moreover, the Veteran himself indicated that his multiple service-connected disabilities affected his ability to maintain employment. See April 2011 VA examination for PTSD. Therefore, this grant of TDIU is based on impairment from several service-connected disabilities, and not just a single disability. The issue of entitlement to TDIU from September 4, 2019 to the present is considered moot. The September 2020 JMR shows the following: It was agreed that the Board had committed error in its October 2019 decision in finding that the issue of entitlement to TDIU from September 4, 2019, to the present was moot because the Veteran was already in receipt of a combined schedular evaluation of 100 percent effective September 4, 2019, and in finding that the holding in Bradley v. Peake, 22 Vet. App. 280 (2008) was not applicable in this case. Based on calculations pursuant to the combined ratings table, the Veteran’s combined schedular rating remains 90 percent, even with the 70 percent PTSD rating. The Board provided inadequate reasons or bases as to its finding that the grant of TDIU was not predicated on a single disability, but instead predicated on multiple service-connected disabilities. In making this finding, the Board did not consider the Veteran’s arguments or the September 2019 medical opinion finding that the severity of his PTSD alone renders him unemployable and the favorable evidence of record on this issue. Citing Dr. M.C.’s September 2019 opinion. As the Board did not consider whether the Veteran’s PTSD alone rendered him unemployable, the parties agree that remand is required. Total disability due to individual unemployability (TDIU) can be considered a “single permanent disability” of 100 percent if TDIU is based on a single disability. See Bradley v. Peake, 22 Vet. App. 280, 293 (2008). The Veteran clearly meets the minimum schedular requirements for TDIU. See 38 C.F.R. § 4.16 (a). As discussed in greater detail in the October 2019 decision, the Board finds the evidence demonstrates that the Veteran is presently unable to obtain or maintain gainful employment as a result of his service-connected disabilities. Accordingly, a TDIU as of September 4, 2019, is warranted. Other Considerations The Board has considered the Veteran’s statements and the lay statements of record. The Board is required to assess the credibility and probative weight of all relevant evidence. McClain v. Nicholson, 21 Vet. App. 319, 325 (2007). In doing so, the Board may consider factors such as facial plausibility, bias, self-interest, and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. 498, 511 (1995); Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). The Board may consider the absence of contemporaneous medical evidence when determining the credibility of lay statements but may not determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Personal interest may affect the credibility of the evidence, but the Board may not disregard testimony simply because a claimant stands to gain monetary benefits. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board acknowledges the Veteran’s belief that his symptoms are of such severity as to warrant increased evaluations. The lay statements have also been considered. Disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. Therefore, the Board finds that the medical findings, which directly address the criteria under which the disability is evaluated, are more probative than the Veteran’s assessment of the severity of his disability, and the lay statements and the submitted article on anger disorders. The examinations also took into account the Veteran’s competent (subjective) statements with regard to the severity of his disability. In reaching these decisions, the Board considered the doctrine of reasonable doubt; however, to the extent that the Board has denied the Veteran’s claims, the preponderance of the evidence is against such, and the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). M. M. Celli Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.S.E., 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.