Citation Nr: 0004009 Decision Date: 02/15/00 Archive Date: 02/23/00 DOCKET NO. 95-03 791 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 50 percent for service-connected paranoid schizophrenia. 2. Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Appellant represented by: Virginia Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL The veteran and his neighbor ATTORNEY FOR THE BOARD J.M. Daley, Associate Counsel INTRODUCTION The veteran had service from January 1976 to January 1979. These matters are before the Board of Veterans' Appeals (Board) on appeal from June and September 1994 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO), located in Roanoke, Virginia. In March 1997 the veteran testified at a Travel Board hearing; a transcript of that hearing is associated with the claims file. During the pendency of this appeal the RO increased the percentage evaluation assigned to the veteran's paranoid schizophrenia from 30 percent to 50 percent, effective March 1, 1994. Although such increase represented a grant of benefits, the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court") has held that a "decision awarding a higher rating, but less than the maximum available benefit...does not...abrogate the pending appeal...." AB v. Brown, 6 Vet. App. 35, 38 (1993). The veteran has not withdrawn his appeal and thus the Board continues to address that issue herein. FINDINGS OF FACT 1. The veteran's schizophrenia is productive of no more than a considerable inability to establish or maintain effective or wholesome relationships with people and/or considerable industrial impairment under the rating criteria in effect prior to November 7, 1996. 2. The veteran's schizophrenia is productive of no more than occupational and social impairment with reduced reliability and productivity due to such symptoms to include disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships under the rating criteria effective November 7, 1996. CONCLUSIONS OF LAW 1. The schedular criteria for a rating in excess of 50 percent for schizophrenia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996); 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). 2. The veteran is not individually unemployable by reason of his service-connected disability. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background A VA hospital summary dated in June/July 1979 reflects a diagnosis of schizophrenia of the paranoid type. The veteran was unemployed at the time of hospitalization. He was described as well-oriented, with auditory hallucinations, a flat affect, paranoid ideas, autistic thinking and sometimes questionable visual and tactile hallucinations. A neuropsychiatric evaluation was conducted by VA in March 1980. At that time the veteran demonstrated no evidence of schizophrenia. The examiner indicated that the veteran's motivation for vocational rehabilitation was lacking and that the veteran "appears to be convinced that he is schizophrenic and therefore, unable to maintain gainful employment." The diagnosis was adjustment reaction of adult life. The contradiction in diagnoses was discussed per psychiatric review, which concluded that there was no reason to question the hospital diagnosis. In a decision dated in May 1980, the RO established service connection and assigned a 10 percent evaluation for paranoid schizophrenia, effective June 28, 1979. A VA hospital summary dated in May/June 1983 reflects admission of the veteran for chronic paranoid schizophrenia. The veteran was unemployed at that time. During hospitalization the veteran was assigned the task of ward messenger and "worked well" in that assignment. He was referred to the Virginia Employment Agency. The veteran was awarded a temporary total rating for that period of hospitalization. The veteran was hospitalized by the VA in November/December 1985 for chronic paranoid schizophrenia. He reportedly had been employed at a local hospital in the housekeeping department and had started a similar job at Holiday Inn. The diagnostic impression was an acute exacerbation. He was discharged with recommendation for outpatient follow-up and determined employable. The veteran was awarded a temporary total rating for that period of hospitalization. A VA hospital summary dated in July 1986 reflects admission for paranoid schizophrenia. The report shows that the veteran had been working from 8 p.m. until midnight as a housekeeper at a hospital. He reported sleep problems, stated to be exacerbated by social problems or being hassled on the job. He also reported that his medication made him somewhat sleepy during the day. Upon discharge he was characterized as able to resume work. The veteran was hospitalized by the VA in December 1987 for an acute exacerbation of paranoid schizophrenia. At discharge he was determined to be capable of part-time employment. In a rating decision dated in March 1988, the RO increased the evaluation assigned to the veteran's paranoid schizophrenia from 10 to 30 percent, effective December 13, 1987. A VA hospital summary report dated in October 1989 reflects the veteran's admission for alcohol abuse and schizophrenia. The veteran reported that he was mildly depressed and unable to work, drawing criticism from his parents for not working. The veteran refused to attend alcohol treatment. He was determined to be able to return to work one week from date of discharge. A report of VA hospitalization dated March/April 1991 reflects that the veteran was admitted for an acute exacerbation of chronic paranoid schizophrenia. He denied auditory or visual hallucinations and was without suicidal or homicidal ideation. He was depressed. The veteran was awarded a temporary total rating for that period of hospitalization. A January 1994 VA hospital record reflects that the veteran was admitted for a syncopal episode that was not attributed to his psychiatric disorder or to medication therefor. It was noted that he heard voices from time to time and had had visual hallucinations and currently felt depressed. He was noted to be neat, clean and cooperative. His speech was of normal rate and volume and he was coherent. He did not appear depressed. Gave a history of drinking a pint of gin every day or two. He was not acutely homicidal or suicidal or psychotic. A VA physician's final note dated in January 1994 reflects that the veteran had global cardiac enlargement, that his left ventricular ejection fraction was less than 30 percent by one study and 19 percent by another study, and that the discharge diagnoses were syncopal episode, schizophrenia, chronic active hepatitis C, and alcohol abuse. The physician noted that due to the veteran's decreased heart function he should avoid exertion and high physical activity In February 1994, the RO received the veteran's claim of entitlement to increased compensation for his psychiatric disability. Of record is a summary report of VA hospitalization dated in February 1994. The veteran was admitted with report of being "physically and emotionally wore out." He reported hearing voices; he was unable to describe them. He reported having no self-esteem. He also stated that he was worried that his heart was going to "give out" at home. He reported consumption of a pint of alcohol a day. The medical history portion of that report includes note that the veteran had been recently discharged after control of congestive heart failure due to cardiomyopathy. He was noted to have schizophrenia without psychotic symptoms at present. The final Axis I diagnoses were chronic schizophrenia and history of alcohol dependence. His work status was identified as totally and permanently disabled. The veteran was awarded a temporary total rating for that period of hospitalization. In a statement received in June 1994, the veteran reported being unemployed due to his psychiatric disability since January 1993. A June 1994 VA report of a two day hospitalization reflects the veteran's complaints of wanting to get away from his neighbors' constant requests to help with odd jobs. He denied suicidal and homicidal ideation. He was dressed neatly and was cooperative and pleasant. He was discharged with advice to avoid alcohol and drugs. The pertinent diagnosis was chronic paranoid schizophrenia In connection with his appeal the veteran complained of being unable to obtain full employment due to his psychiatric disability. He reported that he tried to work part time but could not cope with stress, think clearly or maintain his attention span. He reported being unable to meet his financial needs. He submitted a pay stub showing earnings for an unspecified period of time. In January 1995, the RO received the veteran's TDIU application. He reported last working full time in January 1989 as a recycler. He reported subsequent janitorial work for three hours a week from September to December 1994 and stated that he left due to disability. He reported having completed high school without other education or training. A report of hospitalization dated in January 1995 shows that the veteran was admitted feeling "overwhelmed." The report notes a past history of cardiomyopathy, hypertension and paranoid schizophrenia. He complained of having had some auditory hallucinations, but denied current auditory and visual hallucinations. He reported having no motivation at work and complained of low energy. He reported a good appetite and sleep and denied crying spells and homicidal and suicidal ideation. He stated that he had been working for four months in maintenance for a company. Examination revealed him to be fully oriented, with normal speech, and logical, goal directed thoughts. His affect was calm. No symptoms of depression were noted. His work status was stated to be "as prior to admission." The Axis I diagnoses were adjustment disorder with mixed features, history of chronic schizophrenia, and history of alcohol dependence. The report of a VA psychological evaluation dated in February 1995 is of record. The veteran reported that he was "getting disorganized" and reported that that was a sign of the beginning of his illness. He complained of being bored at work, following the same routine and having to wear a uniform. He felt that boredom or getting in a rut set off his illness. It was noted that when he started getting disorganized he did not have the concentration to prepare meals or uniforms for work and that he would become depressed and isolate himself. The record notes that the veteran had a 12th grade education, with three years of food service training during his last three years of high school. He reported working various housekeeping and maintenance types of jobs, most recently in housekeeping. He also reported having done lawn care work around his neighborhood from time to time. The examiner noted that the veteran "appears to want to work and to be able to secure jobs easily." The examiner noted that the veteran had some heart problems, for which he was on medication. The veteran denied suicidal and homicidal thoughts. He reported sometimes feeling that he was doing something he had done before and also reported hearing voices and talking to himself. The clinical impression was that the veteran had schizophrenia but appeared more functionally motivated than many people in that situation. The examiner noted that the veteran appeared to be having more difficulty with organization and frustration over not being able to hold jobs for long periods. VA outpatient records dated in 1995 and 1996 reflect follow- up for cardiomyopathy and other physical problems. An April 1995 record indicates that the veteran had been working two nights a week cleaning floors and was tolerating it well, without chest pain. An August 1995 record notes that the veteran also had chronic active hepatitis and a history of alcohol abuse. The veteran was working part time at that time. In November 1995 the veteran was ill and presented for evaluation; the impression was gross hemoptysis. Such resolved in December 1995. In April 1996 the veteran presented complaining of coughing up blood; the impression was hemoptysis, for which he was hospitalized. It was noted that his medical history included hepatitis C and that a 1994 echocardiogram had revealed a left ventricular ejection fraction of 20 percent. He was noted to have severe mitral regurgitation, dilated cardiomyopathy probably secondary to ethanol abuse and active hepatitis C. In a March 1995 rating decision, the RO denied TDIU benefits. In November 1996, the veteran was afforded a VA examination. At that time he reported being unemployed, having last worked in December 1995. He gave a history of working at the Civic Center intermittently for three or four years, and that he was doing a lot of lifting, got sick, and had to quit. The veteran reported feeling pressured and nervous. He also reported feeling sad and tired and complained of a sense of hopelessness due to a lack of money. The examiner noted the veteran to be groomed, alert, oriented and cooperative. His mood was anxious and depressed. He demonstrated some difficulty concentrating and was rather limited in smiling and laughing. His speech, affect and psychomotor activity were within normal limits. The examiner indicated that the veteran did not appear to be actively psychotic during the interview. His immediate and recent memories were mildly impaired, but remote memory was intact. His concentration was markedly impaired and judgment was moderately impaired. The diagnosis was paranoid schizophrenia. A report of VA hospitalization dated in February 1997 includes note of the veteran's long history of hemoptysis thought to be due to cardiomyopathy and mitral regurgitation causing pulmonary hypertension. His schizophrenia was noted to be stable at that time. During hospitalization he was treated for his medical problems. He was discharged with medical management. A VA progress note dated in March 1997 indicates that the veteran had social withdrawal and a low- grade paranoia, making it difficult for him to hold a regular job. The physician concluded that the veteran's psychosis rendered him unable to hold permanent gainful employment. In March 1997, the veteran testified at a Travel Board hearing. The veteran reported last working in 1995 at the Civic Center, but stated that he left that employment because he "couldn't perform" and was unable to get back and forth from work with the cold weather. He indicated that the preparation of getting to work on time made him nervous. He stated he had had to leave early four times in eight months or so of employment. Transcript at 3-6. He also reported missing time from prior jobs. The veteran continued to report that he did not like his work uniform, stating that he would "rather not go to work if I had to wear that particular uniform." He complained that the employer put cameras in and he did not like people watching him, and also reported that his hours were cut down to 2 and 1/2 and that they wanted him to work full time so he quit because he did not want to work full time. He indicated that he had a hard time with routine. Transcript at 8, 10. The veteran related difficulty doing things such as going to church. He testified that he sometimes went to movies and that he watched television. Transcript at 14-16. He indicated that he would lose interest in movies and leave. He reported having a girl he goes to see and having an older friend. Transcript at 18. He reported avoiding people. Transcript at 20. The veteran indicated that he was not working at the time of the hearing. He reported that he had worked for himself doing jobs like cutting grass for almost a year but he quit because he "couldn't take it anymore." Transcript at 21-22. He reported hearing voices. Transcript at 27. He indicted that if he didn't have his psychiatric problem he would be on "some nice job...everyday." Transcript at 28. He stated that he slept a lot during the day. A friend of the veteran, Ms. S., also testified that she never knew the veteran to be violent but had heard him talk of being violent. She stated that the veteran didn't talk about suicide to her knowledge. She related that the veteran had a "structure" he had to follow. She indicated that the veteran had contact with his brothers and sisters. Transcript at 32-38. In a March 1997 statement a VA treating psychiatrist reported that the veteran periodically had an active psychosis, usually with social withdrawal and low-grade paranoia, which made it difficult for him to hold a regular job. Thus, the doctor reported that schizophrenia made the veteran unable to hold permanent gainful employment. In a June 1998 outpatient record the same doctor noted that the veteran was disabled for gainful employment "due to multiple problems," medical and psychiatric. In April 1997, the veteran was again hospitalized, primarily for congestive heart failure. The results of an echocardiogram were pending at discharge. During hospitalization there was a diagnosis of an exacerbation of congestive heart failure. In June 1997, the Board remanded the veteran's claim. In response to the RO's request for a list of medical treatment, the veteran provided a release for the RO to obtain private psychiatric records; the identified facility responded that there was no record of the veteran having been treated at that facility. The RO also attempted to verify and obtain details pertinent to the veteran's employment history. The veteran advised the RO that two of his last places of employment were out of business. The Civic Center responded that the veteran had been employed by a labor pool and had worked at the Civic Center in August 1995 on an as needed basis, supervised by Civic Center employees. The response indicates that the veteran was terminated when he did not report to work when scheduled. Another former employer reported that the veteran was employed from November to December 1994 working 18 hours a week, but did not provide reason for termination. Of record are VA outpatient records dated from August 1996 to January 1998. In March 1997 the veteran was treated for hemoptysis. In October 1997 the veteran reported feeling more paranoid. He reported that he was "working on 100%." More psychosis than usual was noted. Medical findings from 1997 show ischemia and continued heart problems. The veteran was hospitalized in September 1997 to rule out a myocardial ischemia after complaining of symptoms to include chest discomfort. Primary discharge diagnoses did not include schizophrenia. The veteran presented for a VA examination in April 1998. The examiner noted the veteran's history as well as a recommendation that he consider treatment on an ongoing basis, but that the veteran reported he did not have time for such treatment. The veteran reported that he spent 50 percent of his time helping his parents and other relatives, that he also helped the neighbors, and that he went to church and painted and refurbished bicycles. He stated that he had not worked since sometime in 1997, when he was cleaning up service stations and driving a van, indicating that because of his heart condition he was not able to work any longer than the time his various chores took. He reported that he was not violent but would defend himself if threatened. He reported obtaining "great satisfaction" from playing the Lottery numbers, as well as from helping his girlfriend's grandchildren. At the time of examination the veteran was well groomed, with normal speech. His affected was appropriate, though somewhat blunted and he described himself as depressed. Examination revealed some concentration difficulty, with questions needing to be repeated. His recent and remote memory appeared intact. His insight and judgment were fair. He was fully oriented, with logical thought processes and without evidence of loose associations, or hallucinations, ideas of reference or delusions. The examiner noted a history of auditory hallucinations, which, when occurring interfered with social functioning to "a definite degree such that he feels the need to withdraw socially until they resolve." The veteran denied suicidal or homicidal ideation. He also denied insomnia, anorexia. The examiner noted that the veteran displayed no inappropriate behavior and described no obsessive or ritualistic behavior or problems with impulse control. The impression was schizophrenia with "mild residual symptoms." The stated global assessment of functioning (GAF) score was 45. The veteran was afforded a VA examination in June 1999. The examiner reviewed the veteran's medical records and the claims file prior to examination. The veteran complained that it "takes me longer to get things done." He reported that his symptoms had never really changed since service, and that he had a new treating psychiatrist, having felt that the prior one was not doing enough to get his rating increased. The veteran explained that he was not able to hold a regular job because his mind was somewhere else and that he would get a "weird feeling" when working. He reported that he felt as if someone was watching him or out to get him and complained of hearing voices warning him to be careful. The veteran did describe current employment for a large corporation picking up trash and indicated that he worked from five to nine p.m., five times a week. He described the people there as "real cocky" and stated that he felt out of place there. The veteran reported having no hobbies, but stated that he had a lady friend he stayed with part of the time. At the time of examination in June 1999, the veteran demonstrated no abnormal behaviors or mannerisms. His speech was logical and coherent and for the most part goal directed; he did at times demonstrate some looseness of association. His mood was described as euthymic and he demonstrated no objective anxiety. The veteran admitted to auditory hallucinations and paranoid ideation with regard to feeling watched by people. His affect was somewhat flattened and he denied suicidal or homicidal ideation. He told the examiner he would like to attack someone who he felt was watching him. He described some obsessive-type thinking in regard to the clothing he had to wear and described planning out the "safest" route to work. The examiner commented that there was no mention of sleep impairment or impulse control or panic attacks and that there was no indication of memory loss or impairment. The GAF was 50. The examiner summarized that there was moderate symptomatology causing considerable impairment in social and occupational functioning and that such was primarily due to his paranoid ideation that limited his ability to trust and interact with people and to function occupationally. Also of record are Social Security Administration (SSA) records and supporting documentation reflecting that the veteran was determined to be disabled by reason of his heart condition as of January 1994. An explanation of determination reflects that the veteran reported being unable to work because of an enlarged heart, shortness of breath, weakness and emotional problems. The SSA reports include note that records did not show an emotional problem significant enough to prevent the veteran from working in 1990; rather, that during that time he was able to relate to other people and to think and act in his own best interest. Records further indicate that evidence finding the veteran to be totally and permanently disabled, dated in February 1994, was unsupported by the record. In May 1994 a medical examiner for SSA found that the veteran had a psychotic disorder manifested by delusions or hallucinations although there was no catatonia or other grossly disorganized behavior and no emotional withdrawal or isolation. The examiner noted that there was slight restriction in the activities of daily living, moderate difficulty maintaining social functioning, that there often were deficiencies of concentration, persistence of pace resulting in failure to complete tasks in a timely manner, and once or twice there had been episodes of deterioration or decompensation in work/work-like settings that caused the veteran to withdraw from the situation or experience an exacerbation of symptoms. An assessment of the veteran's mental residual functional capacity indicates that he was not significantly limited in understanding or memory, or generally in sustained concentration or persistence activities such as being able to understand and remember detailed instructions, the ability to work in coordination or proximity to others without being distracted by them; the ability to sustain an ordinary work routine without special supervision; and the ability to make simple work-related decisions. He was found to be moderately limited in the ability to perform activities within a schedule and on a regular basis, and moderately limited in the ability to complete a normal workday and workweek without interruptions or an unreasonable number and/or length of rest periods. His social interaction was deemed not significantly limited. He was determined moderately limited in the ability to respond appropriately to changes in the work setting and to set realistic goals or make plans independently of others. He was determined capable of simple repetitive tasks. Other SSA records refer to January 1994 evidence of a reduced rate of heart functioning and that prior to that time his heart was not severe enough to restrict him from all work activity. SSA also noted that the veteran was receiving treatment for his emotional problems and was "expected to improve with continued treatment." Pertinent Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4 (1999). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1999). In determining the disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1, 4.2 (1999), which require the evaluation of the complete medical history of the veteran's condition. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). All benefit of the doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3 (1999). GAF is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p.32.] GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (1999). It should also be noted that use of terminology such as "mild" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (1999). Before November 7, 1996, VA regulations provided that the severity of a psychiatric disorder was premised upon actual symptomatology, as it affected social and industrial adaptability. 38 C.F.R. § 4.130 (1996). Two of the most important determinants were time lost from gainful employment and decrease in work efficiency. Id. The pre-November 7, 1996, schedular criteria for schizophrenia provide for a 50 percent evaluation where the ability to establish or maintain effective or favorable relationships with people is considerably impaired and by reason of the psychoneurotic symptoms, the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. A 70 percent evaluation is warranted where the ability to establish and maintain effective or favorable relationships with people is severely impaired and the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent evaluation is warranted where the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community: there is evidence of totally incapacitating psychoneurotic symptoms bordering on the gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior and where the veteran is demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). Effective November 7, 1996, 38 C.F.R. § 4.130, provides for a 50 percent evaluation for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood; suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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; inability to establish and maintain effective relationships. A 100 percent evaluation is warranted where there is evidence of total occupational and social impairment due to 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130. Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.34l, 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities. 38 C.F.R. §§ 3.321(b), 4.16(b). The issue of unemployability must be determined without regard to the advancing age of the veteran. 38 C.F.R. §§ 3.341(a), 4.19. Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Factors to be considered are the veteran's education, employment history and vocational attainment. Ferraro v. Derwinski, 1 Vet.App. 326, 332 (1991). Analysis In general, allegations of increased disability are sufficient to establish well-grounded claims seeking increased ratings. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). In the instant case, there is no indication that there are additional records which have not been obtained and which would be pertinent to the present claims. The veteran has been afforded a comprehensive VA psychiatric examination by an examiner with access to his history and the claims file. The record also reflects that the RO attempted to and/or obtained records of VA and private treatment identified by the veteran, as well as statements from former employers. The veteran has further been provided opportunity to testify at a hearing. Thus, no further development is required in order to comply with VA's duty to assist mandated by 38 U.S.C.A. § 5107(a). See also Stegall v. West, 11 Vet. App. 268 (1998). In determining the appropriate disability evaluation for the veteran's schizophrenia, the question to be answered is whether manifestations of service-connected psychiatric disability meet (or more nearly approximate) the criteria for a rating in excess of the currently assigned 50 percent. Consistent with the Court's decision in Karnas v. Derwinski, 1 Vet. App. 308 (1991), the Board will discuss the veteran's disability with consideration of the criteria effective both prior and subsequent to November 7, 1996. Because his claim was filed before the regulatory change occurred, he is entitled to application of the version most favorable to him. Id. First, the Board notes that the most probative evidence is the June 1999 report of VA examination as such is the most comprehensive, conducted with benefit of review of more outpatient records and a more contemporary examination of the veteran's mental state. See Francisco, supra. That examiner opined that the veteran had moderate symptoms resulting in considerable impairment and assigned a GAF of 50, a borderline indication of moderate psychiatric impairment. See Carpenter; Richards, supra. SSA records dated in 1994 indicate minimal or moderate difficulty in social and occupational functioning due to "emotional problems." Although the April 1998 VA examiner assigned a GAF of 45, that examiner also characterized the veteran's disability as manifested by only mild symptoms. Consistent with the assessment of only mild disability is the November 1996 VA examination report, noting mild memory impairment, and moderate judgment impairment. Moreover, the SSA, determined the veteran to be only slightly restricted in his activities of daily living with only moderate difficulty maintaining social functioning. None of the competent evidence reflects as overall assessment of the veteran's psychiatric disability as severe or even more than moderate. The most recent examination report concludes that the veteran's schizophrenia results in moderate symptoms and considerable impairment as required for a 50 percent rating under the old criteria. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). Certainly, the competent and probative evidence of record does not demonstrate that the veteran is virtually isolated in the community or that he experiences totally incapacitating symptoms. Id. To the contrary, the evidence shows that the veteran has reported helping relatives and neighbors and that he has a girlfriend and interacts with her grandchildren. Thus, the social and industrial impairment resulting from schizophrenia is consistent with the assignment of no more than a 50 percent evaluation under the old regulation. To warrant a higher (70 or 100 percent) evaluation under the revised regulation, the evidence must show occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood; suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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; inability to establish and maintain effective relationships. Clearly in this case the evidence shows that the veteran is not unable to establish and maintain effective relationships. He has been living with his parents, helps neighbors and relatives, communicates with his siblings, has a current girlfriend and has had others in the past, and reports having other friends. He also reports attending church. Examination reports and treatment records show the veteran's denial of suicidal ideation and violent behavior. A witness also reported at the time of the hearing that the veteran was not violent. Examination reports specifically note the absence of any spatial or other disorientation and are consistent in noting the veteran to be appropriately and well-groomed. Nor does the competent evidence reflect near continuous panic or depression, or illogical, obscure or irrelevant speech. The June 1999 examiner specifically noted that there was no indication of panic attacks, and that the veteran's speech was logical and coherent for the most part. Examination in April 1998 also showed that the veteran's speech was normal. He described himself as depressed, but the examiner noted only that his affect was blunted. The April 1998 examiner further stated that the veteran did not describe or display any inappropriate behavior or obsessive or ritualistic behavioral problems and prior records do not reflect notation of such. Although the June 1999 examiner noted some obsessive-type thinking relevant to what the veteran wore to work or the route he took to get there, that examination did not reveal other factors contemplated by the 70 percent evaluation. Further, the competent and probative evidence does not reflect that the veteran experiences disorientation, memory loss for facts such as names of relatives or himself, or memory loss as to his occupation. Nor, as stated above, does the competent evidence show that the veteran experiences total social impairment, or that he manifests gross impairment in his thought processes or communication, or persistent delusions or hallucinations or inappropriate behavior. The notations in the file as to the veteran's reported "hallucinations" or delusions are intermittent only. Again, as set out, the evidence does not support a finding that the veteran presents a danger to himself or others, or that he is rendered unable to perform activities of daily living due to his schizophrenia to warrant a 100 percent schedular evaluation. The Board also notes that the veteran reports difficulty adapting to stress and there is past evidence in the claims file indicating that his schizophrenia impacts his ability to function both socially and occupationally. However, he is in receipt of a 50 percent evaluation, which, is itself representative of a considerable degree of social and occupational impairment under the old regulations and reduced reliability and productivity under the new regulations. The preponderance of the competent and probative medical evidence is against a finding that the veteran is more than moderately impaired due solely to his schizophrenia. As such a higher percentage evaluation for schizophrenia is not warranted under the Schedule. In regard to the issue of TDIU, the veteran is service- connected for one disorder, which is currently evaluated as 50 percent disabling. Thus, the veteran does not meet the schedular criteria in 38 C.F.R. § 4.16(a). Therefore, the issue is whether the evidence warrants a finding on an extraschedular basis that his service-connected disability precludes him from engaging in substantially gainful employment (i.e., work that is more than marginal that permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). The evidence shows that the veteran has engaged in various jobs over the years and at times apparently has been self employed doing such tasks as yard work and house painting. Among his most recent employment was part-time on-call work for a Civic Center. There is no independent evidence that he has been dismissed from a job due to his psychiatric disorder. The evidence shows that he has multiple nonservice-connected disabilities, including significant heart disease, in addition to service-connected schizophrenia. He physical disabilities impose activity limitations that would clearly affect his ability to work, especially to engage in physical labor for which he might otherwise be best qualified in view of his prior work experience. In January 1994, a VA physician noted that due to the veteran's decreased heart function he should avoid exertion and high physical activity and he has been awarded Social Security disability benefits predominantly, if not exclusively, because of his heart disease. The evidence in support of TDIU benefits consists primarily of a March 1997, note apparently was written on the veteran's behalf, by his former VA treating psychiatrist who reported that the veteran periodically had an active psychosis, usually with social withdrawal and low-grade paranoia, which made it difficult for him to hold a regular job and that schizophrenia made the veteran unable to hold permanent gainful employment. However, the same doctor, in a June 1998 outpatient record, noted that the veteran was disabled for gainful employment "due to multiple problems," medical and psychiatric. The Board places greater weight on the record entry since it reflects a more recent opinion and since it is in a medical document generated in the coarse of the veteran's treatment and that was not prepared on the veteran's behalf. Here also is a ORDER An evaluation in excess of 50 percent for paranoid schizophrenia is denied. REMAND The veteran argues that his schizophrenia renders him unemployable. In the decision above, the Board has denied an increased evaluation based on the lack of competent and probative evidence that the veteran's schizophrenia is manifested by symptomatology severe enough to meet the schedular criteria for more than a 50 percent evaluation. Because the veteran's only service-connected disability is his schizophrenia, the schedular criteria for assignment of a total disability rating based on individual unemployability are not met. 38 C.F.R. § 4.16(a) (1999). Although the veteran has not met the percentage requirements set out in 38 C.F.R. § 4.16(a), a claim for TDIU "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of 'subjective' factors that the 'objective' rating does not consider." Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). The provisions of 38 C.F.R. § 4.16(b) thus allow for extraschedular consideration of cases in which veterans who are unemployable due to service-connected disabilities but who do not meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 3.321 (1999). Entitlement to TDIU must, however, be based solely on the impact of the veteran's service-connected disability on his ability to obtain and maintain substantially gainful work. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (1999). The test is whether the veteran is capable of performing the physical and mental acts required by employment and not whether the veteran is, in fact, employed. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Moreover, the VA Adjudication Manual, M21-1, Paragraph 50.55(8) defines substantially gainful employment as that which is ordinarily followed by the nondisabled to earn a livelihood, with earnings common to the particular occupation in the community where the veteran resides. This suggests a living wage. Ferraro v. Derwinski, 1 Vet. App. 326, 332. The ability to work sporadically or obtain marginal employment is not substantially gainful employment, Moore v. Derwinski, 1 Vet. App. 356. 358 (1991). Marginal employment generally shall be deemed to exist when a veteran's earned annual 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. Marginal employment may also be held to exist, on a facts found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). Based on the above the Board notes that the veteran's reported part-time employment is not decisive to the question of whether he is unemployable by virtue of his schizophrenia. The Board acknowledges the representative 's argument as to the RO's noncompliance with the Board's June 1997 remand request. At that time the Board requested a VA examiner to comment on the impact of the veteran's schizophrenia on his employability. The examiner did not provide such opinion. Again, although the veteran reported part-time employment at the time of his June 1999 examination, it is not clear from the record whether such employment is substantially gainful as defined by the regulation. The Board notes the veteran's past employment history, to include other periods of only part-time employment. A further question arises with consideration of the medical evidence of cardiac disease impacting the veteran's ability to work. The Board is obligated by law to ensure that the RO complies with its directives, as well as those of the Court. The Court has held that where the remand orders of the Board or the Court are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Moreover, with a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that the veteran can perform work that would produce sufficient income to be other than marginal. See Friscia v. Brown, 7 Vet. App. 294 (1994), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). Also, the Court has held that when it is claimed that service-connected disabilities prevent a veteran from obtaining and retaining substantially gainful employment, the examining physician should address the extent of functional and industrial impairment which results from the veteran's service-connected disabilities. Gary v. Brown, 7 Vet. App. 229 (1994). Thus, additional information is needed regarding the veteran's part-time job emptying trash in order to determine whether this is marginal or substantially gainful employment, and with respect to the limitations resulting solely from service-connected schizophrenia, without regard to the veteran's age or his nonservice-connected disabilities. Accordingly, this claim is returned to the RO for the following: 1. The RO should ask the veteran to submit an up-to- date employment statement, including detailed information (i.e., tasks involved, number of hours worked per week, dates of employment, hourly wage, total earned income, etc.) pertaining to the employment reported at the time of his June 1999 examination, and/or any other recent employment. 2. The RO should determine whether the veteran's currently reported employment is considered "marginal" as defined by governing regulations. 3. The RO should return the claims file, and a copy of this remand, to the VA examiner who examined the veteran in June 1999 and obtain an opinion as to the impact of the veteran's schizophrenia on his employability. Specifically, the examiner is requested to address whether the veteran's schizophrenia, in and of itself, renders the veteran completely unemployable at above a marginal level, supporting such opinion with reference to manifested symptomatology and limitations resulting from schizophrenia. 4. Thereafter, the RO should re- adjudicate the veteran's claim for TDIU, with consideration of any additional evidence developed upon remand. If the benefit sought on appeal remains denied, the RO must provide the veteran and his representative a supplemental statement of the case, and allow an appropriate period of time for response. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The veteran need take no action unless otherwise notified. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. JANE E. SHARP Member, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 1991 & Supp. 1999), only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1999).