Citation Nr: 0003033 Decision Date: 02/07/00 Archive Date: 02/10/00 DOCKET NO. 99-01 895 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an evaluation in excess of 50 percent for post-traumatic stress disorder (PTSD) on appeal from the initial grant of service connection. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: R. Edward Bates, Attorney at Law ATTORNEY FOR THE BOARD Nancy R. Kegerreis INTRODUCTION The veteran served on active duty from February 1969 to November 1970. This matter comes before the Board of Veterans' Appeals (Board) from June 1998 and January 1999 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the benefits sought on appeal. FINDINGS OF FACT 1. Sufficient evidence for an equitable disposition of the appeal has been obtained. 2. Prior to November 7, 1996, the veteran's PTSD was manifested by symptoms resulting in no more than considerable industrial impairment under the former regulatory criteria. 3. Subsequent to November 7, 1996, the veteran's PTSD was manifested by impaired judgment, disturbances of motivation and mood, and difficulty maintaining effective work relationships. 4. The veteran is currently service connected for PTSD, evaluated as 50 percent disabling, and for amebiasis, at a noncompensable evaluation. 5. The veteran has a high school education with more than one year of additional formal education. His primary work experience has been in association with the Teamsters Union, as a security systems installer, as a contractor, and at carpentry and construction jobs. He has not worked since January 1998. 6. The veteran is not unemployable due solely to his service-connected disability. CONCLUSIONS OF LAW 1. The schedular criteria for a disability rating in excess of 50 percent for post-traumatic stress disorder (PTSD) have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996); 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). 2. A total disability rating for compensation based on individual unemployability due to a service-connected disability is not warranted. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. §§ 3.340, 3.341, 4.16 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background Service medical records do not show treatment for a psychiatric disability. The veteran's DD Form 214, Armed Forces of the United States Report of Transfer or Discharge, discloses that his highest civilian education level was 13 and 1/2 years. Extensive records dating from the mid 1980s reveal diagnoses of PTSD and polysubstance abuse. An October 1991 VA hospitalization report for treatment of a non-service- connected disorder showed that the veteran had been working as a security system installer for seven years and also as a contractor with a friend. PTSD was diagnosed by history. In June 1994, the veteran underwent psychiatric evaluation by W. Weitz, Ph.D., associated with Boca Raton Psychotherapy Associates. The veteran had allegedly repeatedly fired a hand gun at or toward a crowd of people who were setting off firecrackers in a parking lot outside his apartment. Clinical observations indicated that the veteran manifested a positive and cooperative style of interaction and was articulate in his response to questions. During the course of the interview, he exhibited a generally controlled affect, although later in the interview he did demonstrate emotional sadness and tears when focusing on Vietnam-related material. He showed no signs during the interview of any psychotic process. Dr. Weitz offered his professional opinion that the veteran was able to differentiate right from wrong but was evidently experiencing significant psychological turmoil at the time of the incident and had difficulty with respect to impulse control. He had not, however, aimed his weapon at anyone with an intent to injure or to take a life. Although able to differentiate his immediate environment from past combat experiences, the effect of his combat exposure had been to intensify his emotional response to the sudden noise of fireworks on his psychological functioning, resulting in a lack of impulse control. In July 1994, the veteran was tested extensively by Lorraine Wincor, a clinical psychologist. A mental status examination revealed him to be serious, sometimes expressing anger, yet cooperative. He was oriented and showed no impairment in his relationship to reality. Both short-term and long-term memory appeared unimpaired. Affect was appropriately labile throughout the evaluation, as he shed tears over Vietnam nightmares, smiled when referring to his daughter, and exhibited hostility in his attitude toward the criminal justice system. He denied any current or past suicidal/homicidal ideation or auditory/visual hallucinations and did not appear to be attending to any internally-derived stimuli during the clinical evaluation. He evidenced no signs or symptoms of a formal thought disorder. This psychologist believed that the veteran's behavior in the shooting incident had apparently been caused by PTSD symptoms evoked by the noise of firecrackers which had awakened him from a dream about Vietnam. A May 1996 VA Psychiatric Output Evaluation noted that the veteran was unemployed and a ward of the state. He was on a work-release program. He reported depression and anxiety related to his impending release from prison. He had been treated at a Vet Center for a history of seizures and blackouts. A mental status examination revealed that he was alert, oriented, and cooperative. Psychomotor activity was anxious and restless. His speech was coherent, and relevant; his affect tense, and his mood depressed. Reality testing was intact, sensorium clear, memory good, and insight/judgment fair. He had no hallucinations, delusions, or suicidal ideations. The Axis I diagnoses included PTSD, chronic delayed. VA outpatient clinical notes in July 1996 reported complaints of insomnia, irritability, anxiety, and apprehension following his release from prison two weeks earlier. He had been an alcoholic until three years before. At this time, he was cooperative, irritable, tense, and suspicious. His speech was coherent and relevant; his mood was irritable and depressed. An August 1996 VA outpatient mental health clinic record noted that he had been attending a PTSD group on a regular basis. He had been having difficulty coping with the outside world after his release from prison, although he did have employment. The assessment was PTSD, chronic, delayed. During two September 1996 VA mental health clinic sessions, the veteran spoke at length of his experiences in Vietnam. He was noted to be tense, isolated, and restless, with pressured speech. Although irritable, he managed to contain his anger. In October 1996, he discussed problems at work, expressing his belief that someone was deliberately doing things to aggravate him. He complained of getting only three or four hours of sleep a night, which made him irritable the next day. PTSD symptoms included insomnia, isolation, irritability, distrustfulness, and difficulty coping with stressors. A report from a former employer indicated that the veteran had been terminated from employment in February 1997 for insubordination. During a termination interview, he had alleged that his supervisor was incapable of accepting corrective criticism as to how to improve shop performance. The supervisor commented that, whereas the veteran's reliability was good, his attendance needed much improvement, his cooperation was below par, and he had too many of his own ideas on how to do his job. He was not eligible for rehire because he did not work well with others. In June 1997, Daniella David, M.D., Medical Director, Specialized Inpatient Post Traumatic Stress Disorder Unit (SIPU) at a VA medical center, wrote that the veteran had been admitted to the SIPU for the treatment of chronic PTSD for a three-month period. A VA mental health clinic notation that month reported that the veteran was anticipating the program at SIPU and understood that he would have to keep his impulsive behavior under control. Symptoms included insomnia, hypervigilance, intrusive thoughts, nightmares, and increased depression. The discharge summary from SIPU, reflecting treatment from June to August 1997, noted a history of symptoms comprising difficulty falling asleep, combat-related nightmares about twice a month, intrusive memories and images related to Vietnam experiences, infrequent flashbacks, and hypervigilance, irritability, and increased startle response. He complained of being unable to tolerate crowds and of decreased concentration. During his stay at SIPU, he returned on time from his passes, maintained abstinence, and was not verbally or physically abusive. On discharge, his condition had improved. The Axis I diagnosis was chronic PTSD of moderate severity; ethanol and multiple substance abuse in remission. The Axis V Global Assessment of Functioning (GAF) was 45. In August 1997, the veteran was examined by a physician associated with the Department of Human Resources, Office of Community Services, for eligibility for public assistance. It was noted that he had been hospitalized since the prior June for PTSD related to military combat and that he needed time to readjust to the community. He was found unable to work for two months, but able to work henceforth. The prognosis of his disability was considered fair. A December 1997 letter from Dr. David disclosed that the veteran had been treated at SIPU for PTSD for approximately three months. He had attended group therapy to process his psychosocial dysfunction and combat related trauma, as well as individual therapy as needed. In January 1998, the veteran underwent a VA general medical examination. Medical history revealed several hospitalizations for PTSD, the most recent being in the summer of 1997. At that time, he had been found to be hepatitis B and C positive. He stated that he worked in construction when he was able. Physical examination revealed a chronically ill-looking, haggard individual in no acute distress. Diagnoses were liver dysfunction due to hepatitis B and C; PTSD; left inguinal hernia; and external hemorrhoids. A VA psychiatrist noted in May 1998 he had reviewed the claims file before his evaluation. The evidence showed that the veteran participated in many combat missions in Vietnam and had subsequently reported several stressors. After his honorable discharge from the Army in November 1970, he went to work for the Teamsters Union for about four years in New York City. He stated, however, that following this job, his work consisted mostly of sporadic construction-related jobs. After receiving a non-service connected pension in 1996, he had stopped working due to difficulty in relating to authority figures at work and PTSD symptoms. Although he had stopped using alcohol and street drugs in 1993, he began binge drinking in February 1998 for a period of seven to ten days, requiring hospitalization at a VA medical center. He had been hospitalized for psychiatric reasons years before for detoxification from alcohol abuse and in 1997 when he participated in a PTSD program. He had begun receiving regular outpatient psychiatric care in 1996 at VA. Subjective complaints included insomnia and three to four nightmares per month. He stated that he thought about Vietnam "all the time," avoided people as much as possible, had a severe startle reaction, and was always on guard. Objective examination showed the veteran to be alert and oriented, well nourished and well developed. He was cooperative and made fair eye contact. Affect was blunted and mood anxious. His speech was clear, coherent, goal- directed, and unpressured, with no flights of ideas or looseness of association. He expressed vague suicidal ideations without intent, but no homicidal ideations, no auditory, or visual hallucinations, and no delusions. Insight and judgment were fair. The examiner provided an Axis I diagnosis of PTSD of moderate-to-severe intensity and an Axis V GAF of 50. He stated that the symptoms of disturbed sleep, nightmares, intrusive thoughts, avoidance of all reminders of Vietnam, irritability, blunted affect, social isolation, hypervigilance, and hyperarousal could best be accounted for by a diagnosis of PTSD and concluded that they had interfered with the veteran's ability to relate to authority figures, which, in turn, had led to a checkered work history. He was socially isolated with limited contacts and his symptoms of PTSD interfered with his sense of well- being. The overall GAF was considered approximately 50. Based on the above evidence, as well as the veteran's service personnel records, a hearing officer granted service connection for PTSD at an evaluation of 50 percent in June 1998. The veteran also received a temporary total evaluation because of VA hospital treatment in excess of 21 days for VA hospitalization from June to August 1997. In September 1998, the veteran submitted a Veteran's Application for Increased Compensation Based on Unemployability, stating that January 1998 was the date his disability affected full time employment, the date he had last worked full time, and the date he had become too disabled to work. He maintained that he was no longer able to deal with authority and that medication had made it impossible for him to operate machinery. A Social Security earnings report, submitted by the veteran's attorney, disclosed yearly earnings in 1995 of approximately $4264, in 1996 of approximately $7208, and in 1997 of approximately $9647. The veteran's attorney also submitted in September 1998 a report and curriculum vitae of C. Schiro-Geist, Ph.D., a professor and director of the Rehabilitation Research and Evaluation Center at the University of Illinois at Urbana- Champaign. The report consists of an extensive analysis of "generally accepted vocational principles" with consideration of all the variables pertinent to a current determination of disability. Under "Stress," it is observed that "an individual who cannot tolerate being supervised may not be able to work even in the absence of close supervision." II. Legal Analysis A. An Initial Evaluation in Excess of 50 Percent for PTSD The veteran contends, essentially, that he suffers severely from PTSD, with frequent flashbacks in color; startle reaction, causing him to dive for cover when subjected to unexpected loud noises; a lack of emotions or feelings for others; and avoidance of other people. He maintains that a PTSD-related incident had caused him to spend three years in a Florida state prison. The veteran has presented a well-grounded claim for an higher disability evaluation for PTSD within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). When a claimant is awarded service connection for a disability and subsequently appeals the RO's initial assignment of a rating for that disability the claim continues to be well grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). This claim involves the veteran's dissatisfaction with the initial rating assigned following a grant of service connection. He filed his claim in August 1996, and all evidence was received and examinations accomplished by May 1998. In June 1998, a hearing officer granted service connection with an evaluation of 50 percent, effective from August 1996, the date of the claim. The veteran appealed. Effective November 7, 1996, the schedular criteria for evaluation of psychiatric disabilities were changed. When a law or regulation changes after a claim has been filed but before the administrative appeal process has been concluded, VA must apply the regulatory version that is more favorable to the veteran. Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). However, where the amended regulations expressly provide an effective date and do not allow for retroactive application, the veteran is not entitled to consideration of the amended regulations prior to the established effective date. Allin v. Brown, 6 Vet. App. 207, 211 (1994); 38 U.S.C.A. § 5110(g) (West 1991). Therefore, as to the instant appeal, the Board must evaluate the veteran's claim for an increased rating from August 1996 to November 7, 1996 under the old criteria in the VA Schedule for Rating Disabilities and from November 7, 1996, under both the old and the current regulations in order to ascertain which version is most favorable to the veteran, if indeed one is more favorable than the other. In his decision granting the veteran service connection for the above disability, the RO reached its decision under the new, revised regulations only. Before the Board may proceed to apply a regulation that the RO has not previously decided, it must first determine whether the veteran will be prejudiced by its actions. Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993). In considering the issue, the Board determines that an evaluation under both the old and the current regulations will not be prejudicial to the veteran because, pursuant to Karnas, he is to be evaluated under the version which is most favorable to him. Disability evaluations are administered under the Schedule for Rating Disabilities, which is designed to compensate a veteran for reductions in earning capacity as a result of injury or disease sustained as a result of or incidental to military service. Bierman v. Brown, 6 Vet. App. 125, 129 (1994). In evaluating a disability, the VA is required to consider the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; Dinsay v. Brown, 9 Vet. App. 79, 85 (1996). In evaluating impairment resulting from psychiatric disorders under the old criteria, social inadaptability is to be evaluated only as it affects industrial adaptability. The principle of social and industrial inadaptability, the basic criterion for rating mental disorders, contemplates those abnormalities of conduct, judgment, and emotional reaction which affect economic adjustment, i.e., which produce impairment of earning capacity. 38 C.F.R. § 4.129 (1996). Great emphasis is placed upon the full report of the examiner which is descriptive of actual symptomatology. The record of the history and complaints is only preliminary to the examination, whereas the objective findings and the examiner's analysis of the symptomatology are the essentials. On the other hand, the examiner's classification of the disease is not determinative of the degree of disability, but the report and the analysis of the symptomatology and the full consideration of the whole history by the rating agency will be. 38 C.F.R. § 4.130 (1996). To warrant a 100 percent evaluation under 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996), the attitudes of all contacts except the most intimate are to be so adversely affected as to result in virtual isolation in the community. There are totally incapacitating psychoneurotic symptoms bordering on 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. The veteran is demonstrably unable to obtain or retain employment. A 70 percent rating is warranted when the ability to establish and maintain effective or favorable relationships with people is severely impaired, with the psychoneurotic symptoms of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 50 percent rating is warranted when the ability to maintain effective or favorable relationships with people is considerably impaired and, by reason of psychoneurotic symptoms, the reliability, flexibility, and efficiency levels are so reduced as to result in considerable industrial impairment. Under the revised code, 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999), for a 100 percent evaluation to apply, the evidence must show 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. For a disorder to warrant a 70 percent disability rating, the evidence must show 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. A 50 percent disability requires that there be 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 1. Evaluation in Excess of 50 Percent Prior to November 7, 1996 From August 1996 to November 7, 1996, the veteran must be evaluated under the prior regulations. Evidence pertaining to this period comprises 1994 psychological examinations, a 1996 VA Psychiatric Output Evaluation, and clinical notes. The preponderance of the evidence for this period is against the assignment of a disability rating in excess of 50 percent for the veteran's PTSD. The objective medical evidence regarding his symptomatology does not reflect any of the criteria commensurate with those required for a 50 percent or higher disability under the old criteria. During 1996 while still incarcerated, the veteran was working in a work-release program. Following his release, he had obtained and was engaged in other employment. Although he had symptoms of insomnia, isolation, irritability, anxiety, and apprehension, he was alert, oriented, cooperative and in good contact with reality. He had none of the disturbance of thought or behavioral process associated with symptoms demonstrating a profound retreat from mature behavior which would warrant a 100 percent disability rating. As to a 70 percent evaluation, the veteran was working. There is no evidence in the record regarding the extent of his socialization with friends, but the assigned 50 percent disability rating reflects the fact that he may have had impairment in maintaining effective or favorable relationships with people. 2. An Evaluation in Excess of 50 Percent After November 7, 1996 Under the prior regulations, the preponderance of the evidence for this period is against the assignment of a disability rating in excess of 50 percent for the veteran's PTSD. Records from November 1996 to May 1998 show continued symptoms related to PTSD, as well as difficulties in employment due to a variety of reasons, not directly related to PTSD symptomatology. During VA hospitalization in 1997 he was described as punctual, abstinent, and not verbally or physically abusive. This behavior indicates his ability to keep his impulsive behavior under control. Other evidence in 1997 reveals that he was considered able to work and apparently did work when physically able. In 1998, on one occasion, however, he apparently had to be hospitalized for a non-service-connected condition. Although the 1998 VA neuropsychiatric examination report noted that the veteran's affect was blunted and his mood anxious, he was not shown to have had any disturbance in thought or behavioral processes, such as fantasy, confusion, panic, and explosions of aggressive energy, representative of typical symptoms warranting a 100 percent rating. Nor does the evidence show severe impairment in the ability to obtain or retain employment due to neuropsychiatric symptoms, aside from impairment due to non-service-connected physical disability or alcohol abuse. The examiner concluded essentially that the veteran's PTSD symptoms affected principally his ability to relate to authority figures, resulting in a "checkered" employment history. The above evidence is thus most commensurate with a 50 percent evaluation. Under the new regulations, the preponderance of the evidence for this period is also against the assignment of a disability rating in excess of 50 percent for the veteran's PTSD. The veteran has shown none of the symptoms requisite for a 100 percent rating. As to symptomatology representative of a 70 percent evaluation, he has not exhibited suicidal ideation; obsessional rituals; illogical, obscure, or irrelevant speech; panic or depression affecting the ability to function; or spatial disorientation. The medical evidence shows a GAF of 50 during VA examination, indicating serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school function, (e.g. no friends, unable to keep a job). American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, at 46, 47 Fourth Edition. Washington, DC, American Psychiatric Association, 1994. A GAF score is highly probative as it relates directly to the level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). On the other hand, the rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the veteran does exhibit occupational and social impairment, the evidence does not show that his inability to work is due principally to PTSD symptoms or that such symptoms had led to an inability to relate to authority figures, as opined by the VA psychiatrist. A recent employer had terminated the veteran's employment due to a poor attendance record, lack of cooperation, and insubordination - - without reference to any behavior symptomatic of PTSD. Moreover, despite his having problems with anger control, the veteran had demonstrated during his 1997 SIPU treatment that he was able to keep his impulsive behavior under control if he so chose. Additionally, a VA general medical examination in 1998 found him physically ill with hepatitis B and C, which could very likely have interfered with his ability to work in the construction trades. The evidence does not show the extent of the veteran's social functioning. When evaluating the level of disability from a mental disorder, a rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Therefore, neither the objective medical evidence nor the veteran's statements regarding his symptomatology approximate the criteria for a 70 percent or higher disability rating. As to symptoms indicative of a 50 percent evaluation, the veteran does exhibit impaired judgment and disturbances of motivation and mood, as well as difficulty in establishing and maintaining effective work and, very likely, social relationships. His GAF of 50 supports a conclusion of serious impairment in social and occupational functions, but without representative symptoms such as suicidal ideation, severe obsessional rituals, or frequent shoplifting. The Board finds, therefore, that he has been appropriately rated at 50 percent. Regardless of the time frame involved, the record does not provide an approximate balance of positive and negative evidence on the merits. The Board is therefore unable to grant an increased rating pursuant to the doctrine of benefit of doubt under 38 U.S.C.A. § 5107. In summary, the preponderance of the evidence is against the assignment of a disability in excess for 50 percent for the veteran's PTSD, regardless of which criteria are used. B. A Total Disability Rating Based on Individual Unemployability The veteran contends that his PTSD has prevented him from obtaining and maintaining a gainful occupation. His claim for a total disability rating based on individual unemployability is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). Where a veteran asserts that a service-connected disorder has become worse, the claim is plausible and, hence, well grounded. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). A statement by a veteran to VA that he can no longer seek or maintain employment is a well-grounded claim for a total disability rating under section 4.16(b). Stanton v. Brown, 5 Vet. App. 563 (1993). The VA has met its duty to assist by obtaining all available relevant evidence, offering the veteran the opportunity of a hearing, and providing thorough and contemporaneous VA medical examinations. The Board is thus satisfied that all relevant and available facts have been properly developed and that no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107. A total disability rating based on individual unemployability may be assigned where the scheduler rating is less than total when the disabled person is, in the judgment of the Board, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, this shall be ratable at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent disability or more. 38 C.F.R. § 4.16(a). In determining whether a veteran is entitled to a total disability rating based upon individual unemployability, neither his nonservice-connected disabilities nor his advancing age may be considered. 38 C.F.R. §§ 3.341(a), 4.19 (1999); Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992). The veteran is currently service connected for PTSD, rated as 50 percent disabling, and for amebiasis at a noncompensable evaluation. His combined service connection evaluation is 50 percent. The veteran clearly does not meet the disability evaluation requirements of 38 C.F.R. § 4.16(a). Consideration is therefore given to whether a total disability rating pursuant to 38 C.F.R. § 4.16(b) might be appropriate. This regulation provides that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Neither the rating board nor the Board has the authority to grant a TDIU rating pursuant to 38 C.F.R. § 4.16(b). Such cases must be referred to the Director, Compensation and Pension Service for extraschedular consideration, if such referral is warranted. The Board herein considers whether there is evidence to warrant such a referral. The issue is thus whether his service-connected disability precludes him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). For the veteran to prevail in his claim for a total compensation rating based on individual unemployability, the record must reflect circumstances, apart from his non-service-connected condition, which place him in a different position than other veterans having a combined 50 percent compensation rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The ultimate question is whether the veteran, in light of his service-connected disorder, is capable of performing the physical and mental acts required by employment, not whether he or he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The veteran must be unemployable solely as a result of service-connected disabilities. In this respect, the veteran states that his PTSD has prevented him from performing adequately on the job and has introduced evidence purporting to support this claim. There is no medical evidence or medical opinion to show that that the veteran is unable to work solely because of PTSD symptomatology. The relevant medical evidence shows that for many years the veteran has had serious problems with anger and impulse control, in part attributable to his PTSD. On the other hand, he has had a long history of problems with drugs and alcohol, and he has other, significant, physical ailments. Although the report from the veteran's former employer is succinct, the information provided does not indicate that employment was terminated due to any PTSD or neuropsychiatric disorder. Rather, the cause of termination was stated to be insubordination. Although no specific example of insubordination was noted, job performance was stated to be below par because of poor attendance, lack of cooperation, criticism of supervisors, and inability to work with others. The Department of Human Resources physician determined several months later that the veteran was able to work. As to the submissions by the veteran's attorney of Social Security wage statements and the report by Dr. Schiro-Geist, neither is probative as to the veteran's ability to work. The Social Security report merely indicates that the veteran apparently did not work steadily, but provided no evidence as to the reason. Dr. Schiro-Geist stated generally that an individual who cannot tolerate being supervised may not be able to work even in the absence of close supervision. It is significant that Dr. Schiro-Geist had not examined the veteran, had not reviewed the claims file, and, most importantly had not provided any opinion as to this particular veteran's physical and mental capabilities in relation to a determination of current disability. This evidence does not create a balance of evidence for and against the claim on which a benefit of the doubt might be based. In conclusion, there is no credible medical evidence or medical opinion to show that the veteran is unable to work solely because of PTSD. On the contrary, the relevant medical evidence indicates that his PTSD is not totally disabling and this service-connected disability had not prevented him from working. Therefore, the preponderance of the evidence is against a referral of the veteran's claim for unemployability for extraschedular consideration. While it is true that PTSD does present industrial impairment, as reflected by the 50 percent compensation rating, there are no circumstances to place the appellant's case in a different position than similarly rated veterans. Van Hoose, supra. Accordingly, a total compensation rating based on individual unemployability is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and the claim for a total compensation rating based on individual unemployability must be denied. ORDER A disability evaluation in excess of 50 percent for post- traumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating for compensation purposes based on individual unemployability is denied. J. SHERMAN ROBERTS Member, Board of Veterans' Appeals