Citation Nr: 21041025 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 13-31 925 DATE: July 7, 2021 ORDER An initial rating higher than 50 percent for posttraumatic stress disorder (PTSD) is denied. A total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran's PTSD has not been manifested by occupational and social impairment corresponding to a 70 percent rating or higher. 2. The percentage requirements for schedular entitlement to TDIU are not satisfied. 3. The Veteran's PTSD has not prevented him from obtaining or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.30, Diagnostic Code 9411. 2. The criteria for TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.19 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 2001 to September 2005, including service in Kuwait and Iraq from April 2003 through January 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matters in June 2015 and January 2021. Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected disabilities in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Diagnostic codes in the rating schedule identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Initial Rating of PTSD For the following reasons, the Board finds that the criteria for an initial rating higher than 50 percent for the Veteran's PTSD have not been met. A. Rating Criteria The Veteran's PTSD is rated under Diagnostic Code (DC) 9411, which pertains to PTSD. 38 C.F.R. § 4.130. Almost all mental health disorders (with exceptions not applicable here) are evaluated under the General Rating Formula for Mental Disorders (General Rating Formula), which assigns ratings based on particular symptoms and the resulting functional impairment. Id. Under the General Rating Formula, a 10 percent disability rating requires: Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent disability rating requires: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events). A 50 percent disability rating requires: 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. A 70 percent disability rating requires: 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.) A 100 percent disability rating requires: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms associated with each evaluation under the General Rating Formula do not constitute an exhaustive list, but rather 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). Thus, the evidence considered in determining the appropriate evaluation of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. Id. Rather, VA must consider all symptoms of a claimant's condition that affect his or her occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-V). Id. at 443; see 38 C.F.R. § 4.130. If the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating in the General Rating Formula, then the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. In this regard, the Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126; Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). In sum, there are two elements that must be met to assign a particular rating under the General Rating Formula: (1) symptoms equivalent in severity, frequency, and duration to the symptoms corresponding to a given rating, and (2) a level of occupational and social impairment corresponding to that rating that results from those symptoms. Vazquez-Claudio, 713 F.3d at 118. While VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment. 38 C.F.R. § 4.126(b). B. Analysis An April 2011 VA treatment record reflects that the Veteran was diagnosed with alcohol abuse, marijuana abuse, and PTSD. He reported feeling down and struggling with legal and marital stressors. He was unemployed, financially strained, and living with his parents during a marital separation. He stated he was no longer using marijuana or alcohol. It was noted that he would benefit from supportive counseling and possible substance abuse treatment. Another VA treatment record dated in April 2011 reflects that the Veteran was last employed doing a seasonal job in January 2010, and had been laid off at the end of the season. He was currently seeking a job. It was noted that he failed two semesters of class the year before. On examination, he was appropriately addressed and well groomed. His mood was pleasant. His affect exhibited a full range. No abnormalities were noted with regard to speech, thought content, or cognitive functions. He had good insight and judgment. A suicidal risk screen shows he denied suicidal ideation. The June 2012 VA examination report reflects that the Veteran was recently divorced and unemployed. He was living with his parents. He had a girlfriend. He planned to go back to college. He had periods of sleep disturbance, nightmares, problems with social relationships, anxiety in large crowds, irritability, and concentration issues. Regarding functional impairment, the examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. The examiner found that for rating purposes, the Veteran's symptoms consisted of depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting, and inability to establish and maintain effective relationships. In his April 2013 Notice of Disagreement (NOD), the Veteran wrote that he had not been able to obtain employment for almost four years. He continued to battle anxiety and depression on a daily basis. An April 2013 VA treatment record reflects that the Veteran denied thoughts about taking his own life. He was generally feeling well, but very unmotivated. He was unemployed and living at home with his parents. He was assessed with probable depression. A September 2013 VA treatment record reflects that the Veteran reported experiencing a racing heart for the past four days, and anxiety and stress. In his October 2013 substantive appeal (VA Form 9), the Veteran wrote that he could not function in the workplace or in a relationship. He stated that if he gets stressed or anxious he has to leave or he ends up in trouble with the law or his family. He stated he had has had multiple "DUIs" (driving under the influence), and multiple jobs and relationships that went "very poorly." He believed his PTSD should be rated at 70 percent. He also wrote that he had lost a wife, countless friends, and relationships because he could not leave his house. He had become a recluse. He stopped being able to handle most social situations, stating he could not even go to the grocery store. In an August 2014 statement, the Veteran wrote that he had applied for a "countless number of jobs" since active service, and that "every single one" did not work out for him. He stated he was unable to hold a job in order to support himself or his family. He further wrote that talking with people was a struggle, including with friends, family, and co-workers. The August 2014 VA examination report reflects that the Veteran related that he lived with his mother and step-father. He was unemployed. He was attending college, but on probation for poor grades. He stated he was unmotivated and could not relate or get along with his classmates, so he often "cut" class. He avoided people at school because he did not want to be seen as a failure. He had dropped out of three schools previously because of negative feelings toward other students. He had just had a baby with his fiancé. He stated that relationships continue to be an "absolute nightmare" for him. He stated he was less interested in being with others, and recently "had to leave a wedding" because other attendees seemed to be more successful than him, and he felt anger and insecurity which led to him feeling anxiety. He stated he did not trust anyone at college, and easily took offense at comments or statements made by others. He had cut down on his alcohol use since the birth of his child, and had also cut down on his use of marijuana, which he used to smoke on a daily basis. He denied suicidal or homicidal ideation. On observation, he was well-groomed, cooperative, and euthymic, and his speech was linear and logical, with no over indicators of a thought disorder at the time of the examination. His insight regarding his mental health was poor, and his judgment was poor. For rating purposes, the August 2014 examiner found that the Veteran's symptoms consisted of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, and chronic sleep impairment. The examiner also listed panic attacks occurring more than once a week, but this was likely a typographical error, as the Veteran has generally not reported panic attacks, and this finding is inconsistent with the finding of panic attacks occurring weekly or less often. In any event, as that symptom corresponds to a 50 percent rating, which has already been assigned, the error does not affect the outcome of this claim. The examiner found that the Veteran's symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although he was generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Board notes that it remanded the claim in June 2015 because the Veteran "challenged the adequacy" of the August 2014 VA examination report. However, the Board did not itself make a finding that the report is inadequate. The Veteran's main concern was that the August 2014 examiner, according to the Veteran, expressed skepticism to him regarding the sincerity of his self-report, and that the examiner found that he had a personality disorder that contributed to his symptoms and functional impairment, in addition to PTSD. See March 2015 VA Form 9. The Veteran also stated that the examiner did not accurately portray the Veteran's statements in the examination report, asserting that the examiner "twisted/distorted my replies." Id. The Board finds that the August 2014 examination report is adequate, notwithstanding its prior remand. The VA examiner found that the Veteran's symptoms were also due to some extent to a co-existing personality disorder, but stated that he was unable to determine "what portion of the indicated level of occupational and social impairment" was attributable to each diagnosis, as there was a "high degree of overlap." As an initial matter, that observation represents the examiner's independent clinical judgment, and does not necessarily render the examination inadequate. Moreover, and significantly, it also does affect the Board's determination, since the examiner was not able to portion out the symptoms and degree of functional impairment to each diagnosis. Consequently, even if the Veteran did have a co-existing personality disorder, the Board assumes in this decision that the entirety of his symptomatology and resultant functional impairment stems solely from his service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (holding that when it is not possible to separate signs and symptoms of a service-connected condition from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected condition under the benefit-of-the-doubt rule). That said, the Veteran has not elsewhere been found to have a personality disorder. Thus, the Board disregards the August 2014 VA examiner's finding on that issue, but does not find that it renders the examination inadequate, as just explained. Finally, there is no indication that the August 2014 examiner misrepresented or downplayed the severity of the Veteran's statements, as he asserts; indeed, the statements recorded in the report are consistent with his statements recorded in other treatment records and examination reports. In the March 2015 VA Form 9, the Veteran wrote that he "opened up to" the examiner and talked about obsessional rituals which interfere with his daily life and that he had considered suicide many times. As will be explained below, the Board finds that assertion is not credible. Accordingly, although the Board remanded the claim in June 2015 to afford the Veteran a new examination in light of his concerns regarding the August 2014 examination, the Board finds the examination report to be adequate. A March 2015 VA treatment record reflects that the Veteran was generally feeling well. He reported PTSD symptoms including anxiety, nightmares, flashbacks, and an inability to be in large crowds. A functional assessment based on his responses to a questionnaire found that his symptoms of depression were in the moderate severe range, and his generalized anxiety symptoms in the severe range. An April 2015 VA treatment record similarly reflects that based on the Veteran's responses to questionnaires, he had symptoms of depression in the moderate severe range, and generalized anxiety in the severe range. A May 2015 VA treatment record reflects that the Veteran reported that he was separated from his fiancé after she abruptly left him. He stated she had health problems, and relocated to live at her father's home. He was without suicidal ideation. He appeared calm in demeanor, but surprised by the abrupt separation. The September 2015 VA examination report reflects the examiner's impression that the Veteran tended to overreport his PTSD symptoms, and that he was a poor historian overall. He attended school full time, which had just recently started. He missed class occasionally. His "other history" had been complicated by alcohol abuse and cannabis use. During a typical day he tried to go to school and then come home to study. He stated he was estranged from his friends and family. He did not know why, but stated, "I blow up," adding that he gets upset and loses his temper. The examiner noted that the Veteran had reportedly been in many physical fights. He stated he had been in physical altercations with his father, cousins, and lots of friends, where "I just hit them." He reported being really irritable, and the examiner observed he did seem edgy and anxious, with a variable range of affect. He did not have suicidal or homicidal thoughts. For rating purposes, the examiner found that the Veteran's PTSD symptoms consisted of depressed mood, anxiety, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. Regarding functional impairment, the examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. The February 2020 VA examination report states that the Veteran continued to have PTSD symptoms that included nightmares, intrusive thoughts, irritable mood, depressed mood, mild memory impairment, sleep disturbance, and anxiety. He avoided going to places, especially large crowds. He felt disconnected from others, was easily agitated, irritable, and had persistent negative emotions. He was hypervigilant about his surroundings. He felt easily overwhelmed and reported low motivation to do things and low energy. He denied suicidal ideation or homicidal ideation at the examination. He last worked part time as a security guard in 2016. The job did not offer steady work shifts as it was dependent on events. He had been unemployed since then due to personal challenges. He stated that before 2016 he had difficulty getting to work on time, attending consistently, and doing his job duties. At the same time, he was in school part time and was "challenged with thriving academically." He reported severe headaches that occurred a couple of times during the week. He stated it felt like his head "will explode," and that they were "debilitating." He reported high anxiety that leads to stomach upset, which resulted in pain and, at times, bathroom use. He was frequently overwhelmed at the job. He had actively looked for security positions. He currently had a girlfriend who lived with him. He did "odd end" jobs. He stated he had become depressed after breaking up with his former girlfriend, and after his son moved out. On examination, he was well-groomed, dressed appropriately, and presented as coherent and logical. His receptive and expressive language skills were adequate. He presented as somewhat anxious. The examiner found that for rating purposes the Veteran's symptoms consisted of depressed mood; anxiety; chronic sleep impairment; impairment of short- and long-term memory, such as retention of only highly learned material, while forgetting to complete tasks; flattened affect; difficulty in establishing and maintaining effective work and social relationships; and difficulty adapting to stressful circumstances, including work or a work-like setting. Regarding functional impairment, the examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. In terms of the impact of the Veteran's PTSD on his occupational functioning, the examiner stated that the Veteran's mood issues related to PTSD caused significant impairment in his ability to function socially and occupationally, as he was prone to high levels of anxiety that appeared to manifest physically with symptoms of frequent severe headaches and stomach upset, difficulty sustaining concentration, intrusive thoughts, and sleep disturbance that caused challenges with consistent performance. In a July 2020 statement (VA Form 21-4138), the Veteran wrote that since 2016 he had called the VA suicide hotline when feeling "desperate for support." He stated he experienced violent tendencies, suicidal ideation, and impulse control. He avoided crowds because he did not trust himself around the general public. A September 2020 VA treatment record reflects that the Veteran described difficulty with mental health symptoms that waxed and waned in severity but had been persistently present since his return from deployment to Iraq. He reported daily usage of cannabis to manage his anxiety symptoms. He endorsed difficulties with symptoms of anhedonia, feeling down or depressed, impaired sleep, low energy, feelings of failure or guilt, impaired concentration, feeling nervous or anxious, worry, difficulty relaxing, feeling restless, irritability, and a sense of dread. He also reported intermittent and fleeting passive suicidal ideation with no specific plan or intent. He stated that his pattern of coping through self-isolation had not been helpful, and had caused conflicts in his current relationship with his girlfriend, and with his mother and step-father. A functional assessment based on his responses to questionnaires determined he had moderately severe symptoms of depression, and severe anxiety symptoms. The Veteran underwent an in-depth psychological evaluation by telephone for treatment purposes at VA in October 2020. The report of this visit reflects that he was living with his fiancé, with whom he had been in a relationship for the past couple of years, and her children. He also shared joint custody with a child, and had custody of him three weekends per month and on holidays. He had not worked since 2016. He acknowledged abusing alcohol from the time he separated from service until the past January (i.e. January of 2020). When asked about hobbies, the Veteran stated he enjoyed camping. On mental status examination, he was oriented to time, place, person, and event. His affect was appropriate. His mood was anxious, depressed, and irritable. His speech and thoughts were coherent. His insight and judgement were average or good. His memory was within normal limits. He did not have hallucinations or delusions. He denied suicidal ideation, intent, or plan. In April 2021, pursuant to the Board's January 2021 remand directives, an examiner reviewed the record to assess the Veteran's reports of suicidal ideation in statements submitted in support of this claim, given the fact that the VA treatment records and examination reports are generally negative for suicidal ideation. The examiner noted the September 2020 VA treatment record, in which the Veteran reported intermittent and fleeting suicidal ideation with no intent or plan. The examiner also noted more recent psychiatric treatment records showing no suicidal or homicidal ideation. The examiner observed that an examination is a "snapshot" of a person, and that mental health is dynamic and ever changing. The examiner stated that the Veteran had experienced suicidal ideation at various points over the years, and that one was hopeful he would receive adequate support and therapy, and experience amelioration of symptoms with consistent therapy. Based on the evidence reviewed above, the Board finds that the criteria for an initial rating higher than 50 percent for the Veteran's service-connected PTSD have not been met. As explained above, to satisfy the criteria for a given rating under the General Rating Formula, two elements must be satisfied. First, the Veteran must have one or more symptoms matching, or equivalent in severity, frequency, and duration to, one or more of the symptoms listed for that rating. Vazquez-Claudio, 713 F.3d at 118. Second, the symptom or symptoms must be shown to cause the degree of occupational and social impairment required for that rating. Id. In this case, the June 2012, September 2015, and February 2020 VA examination reports list symptoms including difficulty in adapting to stressful circumstances, including work or a worklike setting, and inability to establish and maintain effective relationships. Those symptoms are listed in the criteria for a 70 percent rating under the General Rating Formula. See 38 C.F.R. § 4.130. Therefore, that element is satisfied. Because the Board finds that the Veteran has one or more symptoms corresponding to the criteria for a 70 percent rating, the issue of whether his PTSD is also manifested by suicidal ideation is moot. That said, the Board observes that the statement in the April 2021 VA medical opinion that the Veteran has experienced suicidal ideation at various points over the years is not supported by the treatment records or examination reports. With the exception of the September 2020 VA treatment record, the VA treatment records and examination reports dating from 2011 through 2021 show that he has consistently denied suicidal ideation. Although the Veteran has asserted in statements submitted to VA directly in support of this claim that he has experienced suicidal ideation many times, as he wrote in the March 2015 VA Form 9, those statements are inconsistent with the VA treatment records and examination reports, which almost uniformly show he denied suicidal ideation. Thus, the Board does not find it credible that he has experienced suicidal ideation "many times," or off and on at various points throughout the years. That said, the September 2020 VA treatment record does show a report of intermittent and fleeting passive suicidal ideation with no specific plan or intent. That record, and the October 2020 VA treatment record, reflect that it was determined he was not at risk of committing self-harm. Suicidal ideation, regardless of whether there is "evidence of more than thought or thoughts," is a symptom corresponding to a 70 percent rating. Bankhead v. Shulkin, 29 Vet. App. 10, 21-22 (2017); see 38 C.F.R. § 4.130, General Rating Formula. Nevertheless, assuming that the Veteran's PTSD has also been manifested by suicidal ideation, that alone does not satisfy the criteria for a 70 percent rating. In this regard, in addressing the symptom of suicidal ideation, the United States Court of Appeals for Veterans Claims (Court) observed that the "presence or absence of a specific sign or symptom listed in the evaluation criteria is not necessarily dispositive of any particular disability level." Id. at 22 (citing Vazquez-Claudio, 713 F.3d at 115) (emphasis in original). That observation is in keeping with, and indeed cites to, the holding in Vazquez-Claudio that to satisfy the criteria for a given rating under the General Rating Formula, the symptom or symptoms must also cause the degree of occupational and social impairment required of that rating. Here, the Board finds that neither the Veteran's reported suicidal ideation, nor any of his other symptoms, cause the degree of occupational and social impairment corresponding to a 70 percent or 100 percent rating. The June 2012 and February 2020 VA examiners found that the Veteran's symptoms caused reduced reliability and productivity. The August 2014 VA examiner found that the Veteran's symptoms caused occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although he was generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The level of occupational and social impairment found in these reports corresponds to the criteria for a 50 percent and 30 percent rating, respectively. See 38 C.F.R. § 4.130. These findings are probative, as they represent the conclusions of medical professionals specializing in mental health, and are based on examination of the Veteran and review of his medical history. The Veteran has not submitted probative evidence showing that his occupational and social impairment more nearly approximate deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, which is the level of functional impairment required for a 70 percent rating. The Board has considered his statements regarding his challenges obtaining and holding a job, and with regard to his family and social relations. The Board finds they are unreliable and undercut by inconsistencies that vitiate their credibility. More specifically, the September 2015 VA examiner found that the Veteran tended to overreport his PTSD symptoms, and that he was a poor historian overall. This is borne out by the fact that he stated in the August 2013 VA Form 9 that he could not leave his house and had become a recluse, and yet reported attending a wedding at the August 2014 VA examination, and has also reported attending school full time. Although he stated he had to leave the wedding, that was attributed to feelings of inferiority vis-à-vis the other wedding guests. The record does not indicate that he has been unable to leave his house, or go grocery shopping, etc., as he stated in the August 2013 VA Form 9. Moreover, he stated in the March 2015 VA Form 9 that he reported obsessional rituals which interfere with his daily life to the August 2014 VA examiner. However, not only did that examiner not mention obsessional rituals in the report, but this symptom is not mentioned elsewhere in any of the treatment records or examination reports. Similarly, as discussed above, the Veteran stated in the March 2015 VA Form 9 that he told the August 2014 examiner that he had considered suicide many times. The examination report states that the Veteran denied suicidal ideation. As the August 2014 examiner was in a neutral role, and as the VA treatment records and examination reports generally show denials of suicidal ideation, and make no mention of obsessional rituals, the Veteran's assertion that the August 2014 VA examiner did not accurately document his reported symptoms is not credible. On the contrary, his statements in written documents submitted to VA in support of this claim that he experiences obsessional rituals, that he is a recluse who cannot leave the home to go to the grocery store, and that he has considered suicide "many times" bear out the September 2015 VA examiner's observation that the Veteran overreports his symptoms and is a poor historian. The August 2014 VA examiner similarly suspected that the Veteran "overrepresented" his symptoms. In sum, the substantial inconsistencies between the Veteran's assertions in statements submitted directly in support of this claim, and what is shown in the treatment records and examination reports, their relatively extreme nature such as his assertion that he could not leave the home to go to the grocery store, and the fact that he has been found to overreport his PTSD symptoms and to be a "poor historian," renders them unreliable in terms of establishing a more severe level of occupational and social impairment. By the same token, the Veteran's reported history at the September 2015 examination that he had been in many physical fights, including physical altercations with his father, cousins, and lots of friends, where "I just hit them" is not reliable or sufficient in itself to establish a more severe level of occupational and social impairment. As noted, the examiner did not find him to be a reliable historian, and did not find that the Veteran's symptoms included impaired impulse control such as unprovoked irritability with periods of violence. Moreover, and in the alternative, even if that symptom were established, the level of occupational and social impairment required for a 70 percent rating is not satisfied, as explained above. With regard to the Veteran's stated difficulties in obtaining and holding down a job, the Board similarly finds they are not sufficient to establish a more severe level of occupational impairment. The record shows that he has lived with his parents or with a partner throughout much of the period on appeal, which indicates he may have been in a financial position that has not required he secure a stable income. For example, he may not have had to pay rent or utilities. Thus, the fact he has not had a steady job and has had long periods of unemployability cannot be bootstrapped into a finding that this establishes a more severe level of occupational impairment with a psychiatric origin. Again, the Board notes that it also finds his statements are generally not reliable in themselves, and accords more probative weight to the findings of the mental health professionals who assessed a level of occupational and social impairment corresponding to a 50 percent rating or lower. In addition, although the August 2014 VA examiner found that the Veteran had poor insight into his mental health condition, and poor judgment, that examiner did not find that the Veteran had deficiencies in most areas, and the VA treatment records generally do not show impairment with regard to judgment or thinking. While deficiencies in judgment or thinking are not necessarily required to be shown in order to establish deficiencies in most areas for purposes of a 70 percent rating, since those are only listed as examples, the Board finds that the fact that the Veteran's judgment and thinking have generally been assessed as normal is an additional factor supporting the conclusion that his level of occupational and social impairment does not more nearly approximate deficiencies in most areas, but rather is more readily captured by the level of occupational and social impairment corresponding to a 50 percent rating or lower. The Board notes that the Veteran's functional impairment has also been attributed to some extent to his use of alcohol and marijuana. The April 2011 VA treatment record reflects that he reported he had stopped using alcohol, but the October 2020 VA treatment record states that he acknowledged abusing alcohol from the time he separated from service until that past January, i.e. January of 2020. Service connection for a substance use disorder has not been established. However, as it is unclear from the record to what extent the Veteran's functional impairment is due to his use of alcohol or marijuana, and as the VA examiners generally attributed his level of functional impairmentas determined by the examinersto his service-connected PTSD, the Board has assumed for purposes of this decision that his symptoms and resulting functional impairment are due solely to his PTSD. See Mittleider, 11 Vet. App. at 182. As explained above, that level of occupational and social impairment does not satisfy the criteria for a rating higher than 50 percent, notwithstanding his assertions regarding employment challenges. Similarly, the Board has considered the Veteran's report of severe headaches and stomach upset at the February 2020 VA examination. Service connection has not been established for a headache or stomach condition. Moreover, despite his report of experiencing severe "debilitating" headaches twice per week, the VA treatment records generally do not show complaints or treatment for headaches. The only exception is a September 2020 VA treatment record, in which he reported experiencing headaches in the past week. An October 2017 shows he denied headaches. Headaches or migraines are not otherwise mentioned in the records. The VA treatment records show a complaint of right-sided abdominal discomfort in October 2017, but do not otherwise show complaints of abdominal or gastrointestinal problems during the period under review. They show an earlier diagnosis of gastroesophageal reflux disease (GERD), but do not indicate that he had complaints associated with GERD during the period under review, or that such may be related to his PTSD. Moreover, apart from the one-time statement at the September 2020 VA examination, the Veteran has not ascribed his difficulty working to headaches or stomach issues, but rather due to lack of motivation and interpersonal issues with co-workers. Finally, the February 2020 VA examiner considered those symptoms, and still found a level of occupational and social impairment corresponding to a 50 percent rating. The Board also notes that the Veteran's routine behavior, self-care, and conversation have not shown to be abnormal or deficient. His thought process, thought content, and speech have consistently been assessed as normal on examination. Accordingly, because the Veteran's PTSD symptoms have not caused deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but rather cause a level of occupational and social impairment more nearly approximating an 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, or reduced reliability and productivity, the criteria for a 70 percent rating have not been met at any point during the period under review. See 38 C.F.R. § 4.130; Vazquez-Claudio, 713 F.3d at 118. By the same token, the criteria for a 100 percent rating have not been met, as the record shows that the Veteran does not have total occupational and social impairment. See id. On the contrary, he has helped care for a child and has had a partner for much of the time period under review. Moreover, he had had sporadic work, including work as a security guard which he states did not offer steady employment because he was only needed during specific events. See February 2016 VA Examination Report. He also attended school on a full or part-time basis. See September 2015 VA Examination Report; February 2020 VA Examination Report. Thus, the preponderance of the evidence weighs against total occupational and social impairment. Therefore, because the required level of occupational and social impairment for a 100 percent rating is not established, the criteria for a 100 percent rating are not met, regardless of whether he has symptoms matching or equivalent in severity, frequency, and duration to the symptoms listed for that rating. See id. That said, the record shows he has not had any of the symptoms listed for that rating. Regarding equivalency, as his symptoms are readily captured by the criteria for lower ratings, they cannot, as a matter of logic, be equivalent to the symptoms listed for a 100 percent rating. As the preponderance of the evidence is against a rating higher than 50 percent for the Veteran's PTSD, there is not an approximate balance of positive and negative evidence; therefore, the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 16533 at *10 (Fed. Cir. June 3, 2021); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 U.S.C. § 5107. TDIU A. Law Total disability ratings for compensation may be assigned, where the schedular rating is less than 100 percent, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of one or more service-connected disabilities without regard to advancing age or nonservice-connected disability. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a), 4.19; Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993) (holding that the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability). The claimant's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be considered. 38 C.F.R. § 4.16(b). 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. § 4.15. While the rating is based primarily upon the average impairment in earning capacity, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability, and to the effect of combinations of disability. Id. Substantially gainful employment is defined as work which is more than marginal, and which permits the individual to earn a living wage. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment shall generally be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16(a). Marginal employment may also be established, on a facts-found basis, when earned annual income exceeds the poverty threshold, including but not limited to employment in a protected environment such as a family business or sheltered workshop. Id. Consideration must be given in all claims to the nature of the employment and the reason for termination. Id. Although the Board must fully consider "the effect of combinations of disability" in its determination, "neither the statute nor the relevant regulations require the combined effect to be assessed by a medical expert." Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Indeed, regulation places responsibility for the ultimate determination of unemployability on the Board or rating agency, not a medical examiner. Id. (citing 38 C.F.R. § 4.1(a)). Where separate medical opinions address the impact on employability resulting from independent disabilities, the Board is authorized to assess the aggregate effect of all disabilities. Id. Certain percentage requirements must be satisfied to qualify for schedular consideration of entitlement to TDIU. Specifically, if unemployability is the result of only one service-connected disability, this disability must be ratable at 60 percent or more. 38 C.F.R. § 4.16(a). If it is the result of two or more service-connected disabilities, at least one must be ratable at 40 percent or more, with the others sufficient to bring the combined rating to 70 percent or more. Id. Disabilities of one or both upper extremities, or one or both lower extremities, including the bilateral factor, disabilities resulting from a common etiology or a single accident, and disabilities affecting a single body system such as orthopedic disabilities, will be considered as one disability for TDIU purposes. Id. If the schedular requirements for TDIU are not satisfied, but the veteran is still found unemployable due to service-connected disabilities, the case will be submitted to the Director of the Compensation Service (Director) for extra-schedular consideration. 38 C.F.R. § 4.16(b). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 16533 at *10 (Fed. Cir. June 3, 2021) (holding that if the positive and negative evidence is in approximate balance (which includes but is not limited to equipoise), the claimant receives the benefit of the doubt). B. Analysis The percentage requirements for schedular entitlement to TDIU are not satisfied. More specifically, the Veteran's service-connected PTSD has been assigned an initial 50 percent rating. He has no other disability for which service connection has been established at the time of this decision. Accordingly, as he does not have a service-connected disability rated at 60 percent or higher, or a combined disability rating of 70 percent with one disability rated at 40 percent or higher, the percentage requirements for schedular entitlement to TDIU are not met. See 38 C.F.R. § 4.16(a). For the following reasons, the Board finds that referral of this case for extraschedular consideration is not warranted. In Ray v. Wilkie, the Court held that the phrase "unable to secure and follow a substantially gainful occupation" in section 4.16(b) has two components: one economic and one noneconomic. Id. at 73. The economic component "simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person." 31 Vet. App. 58, 72-73 (2019). As for the "noneconomic component," the Court held that this refers to the individual claimant's "ability to secure or follow" an occupation earning more than marginal income. Id. (emphasis in original). In determining whether a veteran can secure and follow a substantially gainful occupation, the Court stated that attention must be given to several relevant factors: (1) the veteran's occupational history, education, skill, and training; (2) whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g. sedentary, light, medium, heavy, or very heavy) required by the occupation at issue; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue. Id. The Court noted that these potentially relevant factors were not a "checklist that must be completely run through in every case," and that any factor need only be discussed if the evidence raises it as an issue. Id. Regarding the physical limitations factor, the Court stated that relevant considerations include, but are not limited to, the veteran's limitations with respect to lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations. Id. Regarding the mental ability factor, the Court stated that relevant considerations include, but are not limited to, the veteran's limitations with respect to memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Id. As the record shows that the Veteran has not earned more than marginal income during the period under review, the economic component is satisfied. The Board finds that the noneconomic component is not satisfied. Because the Veteran does not have a physical disability for which service connection has been established, only the mental ability factor is relevant. As discussed in detail above regarding the evaluation of the Veteran's PTSD, his statements regarding his employment challenges are not reliable. He stated in the June 2020 VA Form 21-8940 that he has "barely gotten by for the last [ten or more] years," and that he cannot "keep a job." He stated that he will "walk away from everything and everyone in my life." He added that he does not "know the details because it's been so many years since [he] had any kind of normalcy." As explained above, the Veteran has lived with his parents or a significant other such as his fiancé during much if not all of the period under review, and thus may be in a financial position that has not required he secure a stable income. For example, he may not have had to pay rent or utilities. Thus, the fact he has not had a steady job and has had long periods of unemployment does not in itself support a finding of unemployability. The Board also notes that he has attended college full time, and has stated that he had previously dropped out of school due to negative feelings towards other classmates. See August 2014 VA Examination Report (noting he dropped out of three schools because he did not like "uppity kids" or he had to drive a long distance). There is no indication in the record that he would be unable to obtain and maintain substantially gainful employment in a job that did not require much interacting with other people, including perhaps, for example, as a security guard. His prior job as a security guard did not offer steady work shifts. The record does not show he would be unable to maintain a job as a security guard if he were offered steady employment in that role. No VA examiner or treating clinician has indicated that the Veteran's PTSD symptoms prevent him from working. The fact that he has significant occupational and social impairment is recognized by the assignment of the 50 percent rating for his PTSD. But such impairment does not necessarily equate to unemployability, and the Board finds that unemployability due to PTSD is not established. Accordingly, because the noneconomic component is not satisfied, the criteria for referral for extraschedular consideration of TDIU are not met. See Ray, 31 Vet. App. at 72-73; 38 C.F.R. § 4.16(b). As the preponderance of the evidence weighs against unemployability, and thus against referral for extraschedular consideration of entitlement to TDIU, the benefit-of-the-doubt rule does not apply. See Lynch McDonough, supra; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 U.S.C. § 5107. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rutkin, 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.