Citation Nr: 21015058 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 17-62 191A DATE: March 16, 2021 ORDER Entitlement to an initial rating higher than 50 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) on an extra-schedular basis is remanded. FINDING OF FACT The severity, frequency, and duration of the Veteran's PTSD and associated symptoms do not cause occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria are not met for entitlement to an initial rating higher than 50 percent for PTSD. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.15, 4.16, 4.18, 4.126, 4.130, Diagnostic Code (DC/Code) 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from February 1970 to October 1971. These claims were previously before the Board in July 2019 and denied. The Veteran appealed the Board's decision to the higher United States Court of Appeals for Veterans Claims (Veterans Court/CAVC). In April 2020, the Court vacated the Board's decision denying these claims and remanded them back to the Board for further consideration (i.e., an adequate statement of reasons and bases) consistent with agreement in a Joint Motion for Remand (JMR). Entitlement to an increased rating for the PTSD In a rating decision issued in February 2016, the local regional office (RO) effectuated a January 2016 Board decision granting service connection for PTSD and assigned an initial 50 percent rating for this mental disorder retroactively effective from July 19, 2010. The Veteran responded by appealing for a higher initial rating; his attorney contends that a greater 100 percent rating is warranted for the entirety of the rating period under review. The Veteran would be entitled to a higher 70 percent rating if he had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships). See 38 C.F.R. § 4.130, DC 9411.   The Veteran would be entitled to an even higher 100 percent rating if he had 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. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a Veteran’s symptoms, but it must also make findings as to how those symptoms impact a Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the General Rating Formula for Mental Disorders are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms. A Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Here, after again considering this claim, the most probative evidence of record still does not tend to show that the Veteran’s symptoms and consequent occupational and social impairment owing to his PTSD more closely approximate what is required for a higher 70 percent rating or even greater 100 percent rating. His disability is presented in additional evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. But the additional evidence of record does not present findings concerning his disability that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision.   The rating period being considered extends over a decade, and the Board does not need to cite to every piece of evidence in the claims file to accurately assess the overall severity of this disability. Rather, the Board has summarized the evidence and noted certain pieces of evidence it finds are most important and/or best reflect the Veteran’s overall disability picture. For ease of discussion, the Board is reporting the most relevant evidence in yearly increments. 2010 An August 2010 statement by the Veteran’s daughter reflects that the Veteran had bad nerves, the Veteran’s wife cannot “cannot stand any more” dealing with the Veteran’s disability, the Veteran has a bad mood and is irritable, and the Veteran has other symptoms such as an exaggerated startle reflex. She stated that since the Veteran retired [in 2007], his behavior has gotten worse. Private records from Dr. C. Alvarez Rondon reflect the Veteran’s reports of nightmares, that he seldom goes out, that he “sees people who are dead”, that he is nervous, and that he gets annoyed with his wife. 2011 A March 2011 VA examination report reflects that the Veteran had been treated for his psychiatric symptoms, depression, and anxiety, for which he was taking Aripiprazole, Citalopram, and Zolpidem. His treatment included individual psychotherapy. The effectiveness of therapy was reported "good" and the Veteran was observed "doing fine." The reported symptoms were insomnia, anxiousness, depressed mood, poor concentration, irritability, poor impulse control, hopelessness, and alcohol abuse, although his use of alcohol had decreased since 2009, and he had no problematic effects of alcohol use. The examiner observed that the Veteran's general appearance was clean and casually dressed. Psychomotor activity was unremarkable. Speech was unremarkable. His attitude toward the examiner was cooperative. His affect was appropriate. His mood was anxious and depressed. His attention was intact. He was oriented in person, time, and place. Both thought process and thought content were unremarkable. No delusions were observed. As for judgment, the examiner noted that the Veteran understood the outcome of his behavior. As for insight, the Veteran understood that he was having a problem. He reported poor sleep and nightmares. No hallucinations were observed. The Veteran did not have inappropriate behavior. He did not have obsessive or ritualistic behaviors. The Veteran did not have panic attacks, suicidal ideation, nor homicidal ideation. The extent of impulse control was fair with no episodes of violence. He was able to maintain minimum personal hygiene. There was no problem with activities of daily living. Remote memory, recent memory, and immediate memory were normal. The Veteran reported that he had no problems with alcohol use or other substance abuse, and that the quality of his social relationships is fine. He was capable of managing financial affairs, and in full contact with reality. The March 2011 VA examiner found that the Veteran’s symptoms were controlled by continuous medication, and he did not have even transient or mild symptoms which decreased work efficiency and ability to perform occupational tasks during periods of significant stress. His evaluation equates with a 10 percent rating. In essence, although he had symptoms, the Veteran was able to manage them with medication, and thus, his ability to function was not adversely impacted. A May 2011 report by Dr. Rondon reflects that the Veteran reported a panic attack. He reported feeling depressed, tired, and desperate. An August 2011 report by Dr. Rondon reflects that the Veteran reported that he wakes up at night to double check around the house (windows and doors), he hears male voices and sees shadows and a ghost, he is bothered by visits from his sons and grandsons, cannot finish any task, has no interest in doing anything, and has lost sexual desire. She found that upon evaluation, the Veteran was sad, alert, cooperative, distressed, anxious, and hopeless. She also noted that he has immediate and recent memory injury, presents with concentration difficulty, but is well oriented to time, space, and person. She noted that he has good insight. She stated that there is “emotional impairment that does no [sic] enable him to perform any job (CAN NOT WORK) nor behave appropriate with in [sic] his family and social nucleus.”   The probative value of medical opinions is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guarneri v. Brown, 4 Vet. App. 467, 470-71 (1993). There is no requirement that additional evidentiary weight be given to the opinion of a medical provider who treats a veteran; courts have repeatedly declined to adopt the "treating physician rule." See White v. Principe, 243 F.3d 1378, 1381 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). While Dr. Rondon was competent to provide an opinion, the Board notes that it is not entirely supported by the evidence of record. For example, while she stated that he had “injury” to his memory, there are several other records which note that his memory was not impaired. For example, June 2009, July 2009, August 2009, and March 2011 evaluations all not that his memory was not impaired. In addition, while Dr. Rondon noted that the Veteran was not able to behave appropriately within his family and social nucleus, and he reported that he was bothered by his son and grandsons, the vast majority of the evidence reflects that he has remained married, enjoys spending time with his children and grandchildren for a few weeks at a time, has not been arrested, has not abused alcohol or drugs, and has not been violent. 2012 The Veteran had a negative PTSD screening in August 2012, but a positive screening in September 2012. September and November 2012 records reflect that he denied suicidal ideation, denied homicidal ideation, and denied having severe or bizarre symptoms such as hearing voices or seeing things that are not real. 2013 January 2013 VA clinical records reflect that the Veteran had relocated from Puerto Rico to Florida a few months earlier, and initiated psychiatric treatment at the VAMC (VA Medical Center) in Florida. The Veteran was alert, oriented, and cooperative. He was neatly dressed, and his grooming and hygiene were good. His affect was sad, and he was occasionally at the point of tears. His speech was clear and coherent. His thoughts were logical, and goal directed. He denied any suicidal ideation and showed no evidence of psychosis. His insight into his condition was good. His judgment was intact. He reported that his symptoms had adversely affected the quality of his relationship with his wife and had been related to his temper and difficulty in his long-term employment. He continued to require medication treatment and requested both group and individual treatment. He reported that his anxiety is getting worse and is a 10/10 , while is depression is an 8/10. He reported feeling panic around large crowed or children screaming. The Veteran reported having a close relationship with his three children, and a close relationship with his sister. He was still married to his wife of 40 years. He reported that recently he started walking to see if that would help with his difficulties finishing things and doing “nothing lately”. He also reported that he experiences audio hallucinations of people calling his name. Additional records note that he had become depressed more than usual when his wife had temporarily traveled to Puerto Rico to take care of a family member (February 2013), he had terrible nightmares after watching a show on wars (February 2013), he had not had a panic attack in a few years, he was not suicidal or homicidal, his memory appeared intact, his insight and judgment were good or fair, he was oriented, and his sleep was poor (e.g., February, March, April, May, June, July 2013). In March 2013, he was noted to be having a “good week” (an 8/10), using healthy coping skills when feeling lonely and depressed, but also noted that he felt that he cannot establish a relationship with his wife and children, and that his concentration is poor. In May 2013, medication was added to help with sleep, which then improved. The Veteran reported that he keeps busy by bringing his wife to her doctor’s appointments, babysitting grandchildren, or doing housework. In June, he reported that his sleep was improving (he gets 6 hours of straight sleep), although he still has some difficulties if he encounters reminders of war during the day. He also reported that he was less agitated and no longer quick to get angry. He reported improving relationships with his wife and children since he is now more mellow. An August 2013 VA treatment record indicates that the Veteran reported several episodes of brief hallucinations in the past month. He further reported that on good days, he would wake up feeling motivated and energetic, but on bad days, he felt depressed, tired, and had more pain in his joints and would lie down much of the day. He was also noted to have a therapy dog which he enjoys. The plan included changing dosage of medications to help with daytime anxiety. A September 2013 VA treatment record reflects that the Veteran was feeling calmer and less depressed. He reported that he had more motivation and was less tired, felt more rested upon waking up, and no longer having daytime sedation. He had no episodes of hallucinations recently. His marital relationship was noted to be improving as well. The Veteran reported that he was going to take his wife to multiple appointments for her medical condition and would be taking care of a grandchild as well in the next three months. He was also looking forward to a family reunion in December when his family from Puerto Rico will be visiting. An October 2013 note reflects that the Veteran reported that he has improved but he still has bad days where he yells/argues with his wife, and feels bad afterwards. However, he acknowledged that his road rage had decreased. A November 2013 reflects that he was taking care of his granddaughter, to include taking her to school, while his own daughter was recuperating from a fractured ankle. The records reflect that the Veteran continued with group therapy once a week, was oriented, appropriately groomed, and had no overt or reported signs/symptoms of a thought disorder (e.g., September, October, November 2013). 2014 A January 2014 record reflects that the Veteran reported that he had been able to see his son and grandson who came from Puerto Rico for the holidays, and the Veteran was looking forward to seeing his grandchildren in June. A February 2014 record reflects that he reported having increased nightmares and guilt feelings, An April 2014 VA treatment record indicates that the Veteran was able to control his anger. The Veteran reported that normally he would have lashed out on people, but lately he had been able to choose a different response. He reported feeling better now both physically and emotionally. No suicidal ideation was reported or elicited. He had appropriate appearance. He was alert and oriented with time, place, person, situation. He had unremarkable psychomotor activity. His attitude was friendly/cooperative. He had appropriate speech, normal memory function, logical/goal-oriented thought process. No delusion, paranoia, nor suicidal or homicidal ideation was found. He had no audio/visual hallucination. His mood was neutral with appropriate affect. His concentration was grossly intact. His judgment/insight was fair. A May 2014 VA treatment record indicates that the Veteran had intermittent nightmares. He reported that he was more socially outgoing and started to play softball with seniors twice per week and felt good with meeting others. Also, he started exercising more. His wife was supportive. He was looking forward to having his grandchildren visit from Puerto Rico in the next two months. He was calm, cooperative with good eye contact, and well-groomed. No psychomotor retardation or agitation was observed. He was spontaneous, logical and coherent. Thought process was goal-directed. He was in good mood. Affect was appropriate. He denied suicidal ideation, homicidal ideation, and hallucinations or delusions: He was not observed to be responding to internal stimuli. He was alert and oriented in all four aspects. He had intact memory and concentration. Insight and judgment were adequate. An August 2014 private psychiatric evaluation by Dr. Cesta reports that the Veteran was friendly and cooperative, his impulse control was intact, his speech was decreased in rate, tone, and volume. He was agitated, and his affect was labile with extensive dysphoria mixed with anger and irritability. His thought content had vague themes of suicidal ideation that were passive in nature without plan or intent. (The Board notes that the vast majority of the VA clinical records reflect that the Veteran had denied suicidal ideation and/or that he was a low risk for suicide.) He expressed previous feelings of homicidal thought directed at coworkers and other individuals who angered him with no thoughts or plans to harm another individual at the time of assessment. The Board notes, however, that the Veteran retired in 2007; thus, his thoughts/feelings towards his co-workers was not during the rating period on appeal, but several years prior. The Veteran reported he regularly hears voices of soldiers from Vietnam, see soldiers from Vietnam, hears gunshots, and relives his experiences from Vietnam. His cognition was found intact. Dr. Cesta opined that the Veteran has severe and pervasive mental illness that has been progressive over time, Dr. Cesta stated that the Veteran’s symptoms of PTSD became so severe as to force him to leave full-time employment in 2007 although he wished to continue working. 2015 The Veteran reported that he was doing better and less anxious about family stressors at the beginning of 2015. He and his wife spent time and activities together, and he was keeping physically active during the day with house projects, however his increased startle response was still present. He reported that he has been able to handle problems with noise and his neighbor in a calm situation, and has been able to control his temper (February 2015). He also reported that he had a rough month with an added stressor of his wife’s health (March 2015), and that he was feeling lonely since his wife left for Puerto Rico for six weeks to visit relatives and a terminally ill brother; the Veteran declined to go because of too many triggers from living in Puerto Rico (May 2015). He denied suicidal ideation, denied homicidal ideation, was alert and oriented, had adequate insight and judgment, and had logical though-process (e.g., February, March, May, July, September, October, November 2015). A July 2015 record notes that the Veteran continues to feel connected with his PTSD group and his wife reported to him that she sees a difference in his interaction with people and at home. An October 2015 record notes that he still has intermittent angry outbursts but is now able to control them without getting out of hand. He reported that he feels more depressed and anxious, although his sleep is more stable. His anxiety was heightened by his VA disability appeal. In November, he noted that he snaps at his wife, but they continue to have a supportive relationship.   2016 The Veteran was oriented, alert, had appropriate speech, normal memory, logical through process, fair/intact judgment and concentration, and no suicidal or homicidal ideation (e.g., January, April, September 2016). The Veteran was still married and his wife was still supportive (he stated that she deserved a medal for putting up with him a she continues to overact to noises or when she doesn’t follow instructions)(January), he spent the holidays with family and with a couple of friends from Puerto Rico (February), he was looking forward to his son’s upcoming visit, those of his daughter and grandchildren who will visit in the summer (April). A July 2016 VA examination report reflects that the Veteran reported that he and wife would argue, but he described his wife as being supportive. He noted he also experienced difficulties with sexual intimacy. He noted positive relationships with his three adult children. When his grandchildren visited, he enjoyed them, but he would become overwhelmed with them due to their yelling and screaming. He reported he had a few close friends, but he did not like to socialize with many people. He reported he preferred to be at home. He enjoyed reading. He stated he would be anxious driving on the highway. The Veteran attended church on Sundays. He had a service dog and would take him for walks. His self-reported symptoms were anxiety, ruminations, anxiety while driving/flying in an airplane, easily distracted, physiological reactivity, hypervigilance, easily startled, depressed mood, increased appetite, sleep disturbance (fragmented sleep), nightmares, fitful sleep, avoids trauma triggers, irritability, anergia, mild anhedonia, easily frustrated, lack of patience, avoids loud and crowded venues, feeling of being easily overwhelmed. The July 2016 examiner found the following symptoms: depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbance of motivation and mood, and difficulty in adapting to stressful circumstances, including work or worklike setting. During the examination, the Veteran was oriented in person, place, time, and purpose of visit. He was alert, appropriately groomed and attired. He ambulated independently. He had good, appropriate eye contact. His speech was within normal limit. His attention/concentration was mildly impaired. Psychomotor behavior was within normal limits. No delusion was noted. His thought process was goal-oriented and linear, his mood was euthymic, and his affect was congruent with ideation and appropriate to situation. No suicidal ideation or homicidal ideation was reported nor evidenced. Memory was grossly intact. Insight and judgment were adequate. As for perceptual disturbances, the Veteran denied it and the examiner did not observe that he was responding to internal stimuli. The Veteran reported he sometimes thought his name was being called. The July 2016 examiner considered all of the Veteran’s reported symptoms and those noted upon evaluation (whether or not in the rating criteria), and opined that the Veteran's psychiatric symptomatology was productive of occupational and social impairment with reduced reliability and productivity; this equates with a 50 percent rating. An October 2016 record notes that the Veteran reported that his anxiety had intensified during a hurricane but was now lessened and he is looking forward to living in a house in a 55+ community, where he and his wife can spend more time in the backyard gardening. A November 2016 record reflects that he reported that he is sleeping better, is less vigilant, and is less startled by noises, in his new home. 2017 In 2017, the Veteran continued to deny suicidal or homicidal ideation, and he was alert, oriented, had intact memory, had adequate/fair/good insight and judgment, and had goal-directed thought processes (e.g., January, February, April, May, August 2017). A January 2017 VA treatment record indicates that the Veteran denied having any difficulty in caring for himself. A February 2017 VA treatment record indicates that the Veteran reported having more nightmares with sweats, and difficulty sleeping. A March 2017 VA treatment record indicates that the Veteran reported settling well into a senior community that he recently had moved into, and enjoying gardening. He reported that he still gets frustrated or irritable if his personal space or personal property is disorganized by others. A June 2017 VA treatment record indicates that the Veteran reported exacerbation of PTSD symptoms, now that it was rainy/hurricane season in Florida. The rainy season reminded him of monsoon rains in jungles in Vietnam. He denied suicidal or homicidal ideation. He reported he enjoyed walking, listening to music, singing, and church activities. An August 2017 record reflects that the Veteran’s three grandchildren from Puerto Rico had visited him for five weeks, and although, he initially enjoyed being with them for the first few weeks, once they started to bicker with each other, he became irritated by their noises, especially screaming and crying. To keep from having an angry outburst, he would step outside or take a trip. A December 2017 VA treatment record indicates that his living situation was much better after moving to a senior community. The progress was assessed stable, with no significant change from the previous session. 2018 The Veteran was alert, oriented, participated in PTSD group discussions, and was relatively stable, not suicidal, and not homicidal (e.g., April, May, June, July, August, November 2018). A June 2018 VA record reflects that the Veteran reported an exacerbation of hypervigilance when he was left home alone for two weeks when his wife left for Puerto Rico. He stated that he did not feel safe and would wake up intermittently to check the house. He reported that he again feels safe now that his wife is back home. He is looking forward to his daughter and granddaughter vising for two months. An August 2018 record reflects that the Veteran reported very anxious that morning due to waking up later than planned, and had recently been upset with someone who was a “no-show” for repairs at his home. His daughter, who was in the process of moving to be near, was staying with him. A December 2018 record notes that the Veteran reported having more intrusive memories due to the season, but denied a down mood lingering for two weeks at a time. 2019 The Veteran continued to have appropriate appearance, be correctly oriented to time, place, person and situation, be friendly, have appropriate speech, have a logical thought process, have normal memory, have adequate/intact/fair concentration/judgment/insight, and deny suicidal and homicidal ideation (e.g., February, March, June, and October 2019). A February 2019 record reflects that the Veteran reported “no major problem”. He did, however, report that he was feeling overwhelmed with house chores and responsibility since his wife went to visit a sick relative two weeks earlier. Although, he noted that he was less vigilant compared to the last times she had gone away. A close friend had passed away in December 2018, and he went to the funeral. His daughter was still staying with him temporarily. A March record reflects that when his wife returned, his level of anxiety decreased. In a February 2019 statement, the Veteran asserted that his PTSD had interfered with his job, and that after he retired in 2007, his symptoms worsened. He asserted that he has put his wife and children through an “inferno with [his] drinking, anger, and bad mood”. However, this is not necessary during the rating period on appeal, as the clinical records routinely reflect that the Veteran does not abuse alcohol, and his alcohol use decreased since 2009. A March 2019 private psychiatric evaluation by Dr. Cesta describes the following result of mental status examination based on a contemporaneous interview with the Veteran. The Veteran was cooperative, appropriate with good impulse control. His speech was flat in rate, tone, and volume. He was not agitated. His mood was "okay", affect dysphoric. He continued to have passive suicidal ideation without plan or intent. He had homicidal ideation intermittently, but not during the interview or directed at a single individual. The Board notes that the contention of homicidal ideation is inconsistent with numerous VA clinical records. The Veteran’s thought process was "perseverative" on topics surrounding Vietnam. During discussions of those topics, Dr. Cesta found that it was difficult for him to be redirected, but the Veteran was capable of giving a linear account of his life. There was no flight of ideas or looseness of associations, nor did he endorse any perceptual alteration such as auditory, visual, or tactile hallucinations. His cognition was intact. Dr. Cesta stated that since the Veteran retired in 2007, his clinical situation has deteriorated. He stated that the Veteran no longer leaves his home except to go medical appointments or group therapy, does not engage in instrumental activities of daily living, communicates only with his wife on a regular basis, and is unable to tolerate interactions outside his home. This statement as to his social interaction is at odds with prior evidence that he goes to church, has a few friends, and plays softball. A March 2019 statement from the Veteran’s spouse reflects her observations of the Veteran over the last fifty years, and is not restricted to the rating period on appeal. She reported that at night she hides objects which can be used as weapons because she is worried that he will have a nightmare and may hit her; although, there is no evidence in the clinical records that he has ever hit her with something. She also reported that he “spaces out” many times when he is driving and something reminds him of Vietnam; however, she did not state that she restricted him from driving. Among other reported symptoms, she also stated that noise levels of the grandchildren bother him so he will go to his room and shut the door. She stated that she has considered leaving him due to his PTSD, but her religion causes her to stay married. A June 2019 VA record reflects that the Veteran reported getting more irritable when his wife questions his driving or tells him to watch out for certain vehicles. October 2019 VA records reflect that he has woken up with anxiety and cold sweats, that he gets startled easily even when in church, and that he is getting quicker to get irritable even toward his wife, but there was no overall change in his PTSD symptoms.   A November 2019 record notes that the Veteran’s son had recently visited, and the Veteran is looking forward to his daughter’s visit the next day. The Veteran also reported that they will be visiting a city approximately three to four hours away which he has always wanted to visit. (This conflicts with Dr. Cesta’s opinion that the Veteran does not leave the home for pleasure.) 2020 For this most recent period the claims file includes an October 2020 report from Dr. Cesta expressing his opinion that, since at least 2007, the Veteran has been completely psychiatrically disabled and incapable of working. Conclusion The Board finds that the frequency, duration, and severity of the Veteran’s constellation of symptoms – as reported by him personally and by family members, and as determined by his treating clinicians, VA examiners, and private clinicians indicate his level of social and occupational impairment is most commensurate with his existing 50 percent rating. The Board has not ignored the private opinions tending to support a higher rating; however, the Board finds that the Veteran’s disability picture most appropriately fits within the parameter of the existing 50 percent rating. The evidence shows that, through therapy sessions and medications, the Veteran has been managing his symptoms; the most probative evidence does not show occupational and social impairment with deficiencies in most areas. This is not to dispute he has symptoms, but it is not merely the symptoms that are critical, but also how they affect or impact his occupational and occupational functioning. The VA clinical records overwhelmingly note that the Veteran has been alert and correctly oriented in all spheres – meaning to time, place, person, and situation, also that he has normal/intact thought processing that is goal directed, that his memory is intact, and that he is not a danger to himself or to others. With regard to social relationships, the Veteran has reported sexual intimacy problems; his wife has stated that she stays with him due to her religion. Nevertheless, they have remained married for more than four decades. Also, notably, he has a close relationship with his three children and looks forward to visits from them and his numerous grandchildren. The Board also acknowledges that the crying/noise/screaming of children can be irritating, and that he finds the need to walk away from them at times; however, he has been able to maintain a relationship with them, including involving lengthy visits (multiple weeks), and he looks forward to those personal interactions. The Board finds it notable that not only did he enjoy visiting with his children and grandchildren, on occasion, but that he actually helped take care of the children. The Board finds that it belies credibility that he would have severe impairment correlating to a higher 70 percent or 100 percent rating and his family would still allow him to watch young children unsupervised. The Board also sees the Veteran’s wife has been away for extended periods of time, and the evidence does not suggest that he has been unable to care for himself during these times. Although he felt overwhelmed with chores, he was not found to be ungroomed, unhygienic, or unable to prepare meals/feed himself. During the rating period on appeal, the Veteran moved from Puerto Rico to a state and then later moved from his home to a home in a 55+ senior citizen neighborhood without evidence that he was unable to adapt to the new locations. Rather, he has been able to acclimate without incident or exception. Despite the opinions of Dr. Cesta and Dr. Rondon, the evidence does not reflect that they ever attempted to have the Veteran hospitalized due to his symptoms or that they ever contacted authorities for assistance because he was a danger to himself or to others. The most probative evidence also does not support the notion that he was ever found wandering neighborhoods, confused, that he was unable to care for himself, that he was homeless, that he refused to leave the home for extended periods (to the contrary, he went to church, to his wife’s appointments, to play softball, and to take his grandchild to school). Additionally, there is no indication he has abused drugs, that he frequently abused alcohol, that he is illogical, that he has been arrested, that he frequently gets lost, that he refuses to bathe/shower, that he forgets the names of family members, or that he cannot be left unattended. His need to check the home for security is not so obsessive in ritualistic terms as to cause significant interference with his functioning, Moreover, although he reported having experienced hallucinations in the context of re-living his experiences in Vietnam, these have not been shown to be pervasive or for any sustained length of time. The Board realizes the Veteran has reported symptoms that may wax and wane (e.g., panic attacks, hallucinations, nightmares). When determining the appropriate rating, it is not necessarily the number of symptoms that a Veteran has and/or the variety of them, but rather the effect of the symptoms on his occupational and social functioning. And, here, to summarize, the most probative evidence shows he has at most occupational and social impairment with reduced reliability and productivity, which is compatible with his existing 50 percent rating. The Board certainly appreciates the Veteran’s honorable service and is mindful of his receipt of the Combat Infantryman Badge (CIB). This decision is in no way meant to diminish his very commendable service. However, for the reasons and bases discussed, a higher initial rating is not warranted. And, as the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND Entitlement to a TDIU The Board has found that a higher schedular rating is not warranted for the Veteran’s PTSD when considering the impact of this service-connected disability on his occupational and social functioning. However, the derivative issue of his entitlement to a TDIU does not include consideration of his social functioning and, instead, is limited to considering whether his service-connected disabilities (so not just his PTSD but additionally when factoring in the several others) preclude him from obtaining and maintaining employment that would be considered substantially gainful versus just marginal in comparison or not at all.   The Veteran does not presently have sufficient ratings for his service-connected disabilities to meet the threshold minimum rating requirements for a TDIU under 38 C.F.R. § 4.16(a) because, prior to July 2019, he had more than one disability and a combined rating of 50 percent (a 50 percent rating for his PTSD and 0 percent (noncompensable) ratings for a history of malaria and a scar). And, since July 2019, he has had multiple service-connected disabilities but that combine to a rating of 60 percent rather than to the required 70 percent. Moreover, these multiple service-connected disabilities cannot be considered as one disability due to their nature (i.e., do not result from common etiology or single accident, do not represent multiple injuries incurred in combat, do not affect both upper extremities or both lower extremities or a single bodily system). According to § 4.16(a), to qualify for a schedular TDIU absent one of those exceptions, if a Veteran has one disability, it must be rated as 60-percent disabling or more, and if he has two or more disabilities they must have a combined rating of at least 70-percent disabling with at least one having a 40 percent rating. In this circumstance, where the Veteran does not have sufficient ratings for his service-connected disabilities to warrant consideration of his entitlement to a TDIU under § 4.16(a), the Board’s analysis is limited instead to determining whether this claim should be referred to the Director of the Compensation Service to consider whether this TDIU benefit is warranted alternatively on an extra-schedular basis under the special provisions of § 4.16(b). Anderson v. Shinseki, 22 Vet. App. 423, 428-29 (2009). The Board will refer the matter to the Director under § 4.16(b), however, only when Board determines there is sufficient evidence the Veteran may be unemployable due to his service-connected disability(ies). The Veteran has a bachelor’s degree in accounting. Prior to his retirement in 2007, he had worked as an auditor for the Internal Revenue Service (IRS) for 28 years; he retired from federal service after 30 years of employment (two years in the military and 28 years working for the IRS). VA clinical records dated in 2009, so since his retirement, show the Veteran reported that, during his years working, he had noticed that he was irritable with supervisors – though he admittedly had no disciplinary actions taken against him. He reported that the past “6-7 years” (so including when he was still working) had been hard for him psychologically. The examiner observed the Veteran had retired from his job in August 2007 and that “changes related to this stage of life could be producing anxiety reactions, though he denied any significant event happened recently.” The Veteran’s wife reported that she had noticed a change in him for the last 4-6 years (so, again, dating back to when he was still employed). Both private examiners have opined that the Veteran is unable to again work in any substantially gainful capacity due to his PTSD, although the VA clinicians have not found that level of severity of his PTSD and consequent impact on him occupationally. Symptoms that may affect his employment in a white-collar job would be difficulty with concentration, intrusive thoughts, fatigue owing to interrupted sleep, and anxiety. The Board consequently is referring this TDIU claim to the Director of the Compensation Service for consideration of whether this benefit is warranted on an extra-schedular basis under the special provisions of § 4.16(b). Accordingly, to this end, this claim is REMANDED for the following action: Refer this TDIU claim to the Director of the Compensation Service for consideration of whether this benefit is warranted on an extra-schedular basis pursuant to 38 C.F.R. § 4.16(b). KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Wishard 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.