Citation Nr: 1225932 Decision Date: 07/26/12 Archive Date: 08/03/12 DOCKET NO. 09-13 914 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD), for the period from September 22, 2008. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from November 1962 to July 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which granted service connection for PTSD. The Veteran appealed seeking a higher initial rating for his PTSD. Subsequently, in July 2010 the Board denied an initial rating in excess of 30 percent for the period from April 7, 2006 to September 21, 2008 and remanded for further development the issue of a possible staged rating from September 22, 2008. The Board also notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans' Claims (Court) held that a TDIU claim is part of an increased disability rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for a TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the October 2010 VA examiner has noted the effects on the Veteran's occupational and daily activities resulting from his PTSD. In light of Rice and the VA examiner's report that the Veteran's occupational and social impairment were affected, at least in part, as a result of his service-connected PTSD disability, the Board finds that the Veteran's increased rating claim includes a claim for TDIU. This claim, therefore, has been added on the title page as an additional claim entitled to current appellate review. FINDINGS OF FACT 1. For the period from September 22, 2008, the evidence does not show that the Veteran's PTSD results in occupational and social impairment with reduced reliability and productivity. 2. The Veteran is service-connected for residuals of small cell carcinoma of the lung with a 30 percent disability rating; for PTSD with a 30 percent disability rating; for coronary artery disease, status post myocardial infarction and angioplasty, with a 30 percent disability rating; for diabetes mellitus, type II, with a 10 percent disability rating; for peripheral neuropathy of the left lower extremity secondary to diabetes with a 10 percent disability rating; and peripheral neuropathy of the right lower extremity secondary to diabetes with a 10 percent disability rating. 3. The Veteran's overall combined disability rating is 80 percent; in this regard, several of the Veteran's service-connected disabilities result from a common etiology related to service in the Republic of Vietnam, and he is thus deemed to have at least a single disability rated at the 60 percent level. 4. The evidence is at least in equipoise regarding whether the Veteran's service-connected disabilities render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for PTSD, for the period from September 22, 2008, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Code 9411 (2011). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for entitlement to a TDIU have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the issue now on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Given the determination reached in this decision the Board is satisfied that adequate development has taken place and that there is a sound evidentiary basis for resolution of the TDIU claim at present without detriment to the due process rights of the Veteran. The Veteran was notified via letters dated in August 2004, February 2005, and July 2008 of the criteria for establishing service connection for PTSD and then for establishing higher ratings for his PTSD disability, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates in the July 2008 correspondence. After the correspondence dated in August 2004 and February 2005 was issued, the Veteran was granted service connection for PTSD and assigned an initial disability rating and effective date in the rating decision now on appeal. As this claim was more than substantiated in that it was proven, the purpose that the notice is intended to serve has been fulfilled. The subsequent July 2008 VCAA letter is deemed not necessary as no additional notice was required for this claim. Dingess, 19 Vet. App. at 490-91. In addition, since the original higher initial rating claim for PTSD, decided in the July 2010 Board decision, was a "downstream" issue from that of service connection, notice pursuant to the original Court decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), was never required for this issue. See VAOPGCPREC 8-2003 (Dec. 22, 2003). VA also has a duty to assist a veteran in the development of his claim. As a result of the Board's July 2010 remand, the RO scheduled a VA PTSD examination in October 2010 after recent treatment records from the Chattanooga Vet Center and the Chattanooga VA clinic were associated with the claims file. Thus, the Board finds that the duty to assist has been fulfilled as medical records relevant to this claim have been requested or obtained and the Veteran has been provided with a recent VA examination of his higher initial rating claim for PTSD that was bifurcated into two different time periods as a result of the July 2010 Board decision. The Board finds that the available medical evidence is sufficient for an adequate determination of this claim. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with this claim would not cause any prejudice to the Veteran. Increased Rating - Laws and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating 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 their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. In this case, as noted in the Introduction, the Veteran appealed the award of an initial disability rating of 30 percent for his service-connected PTSD. In its July 2010 decision, the Board denied the Veteran's request for an initial rating in excess of 30 percent for PTSD, for the period from April 7, 2006 to September 21, 2008, and remanded for further development the period from September 22, 2008 to determine whether he was entitled to a staged rating. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14. When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. PTSD Historically, service connection for PTSD was granted in the February 2008 rating decision currently on appeal and a 30 percent disability rating was assigned, effective April 7, 2006, pursuant to the rating criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9411 (2011). Under that code and the General Rating Formula for Mental Disorders, ratings may be assigned ranging between 0 and 100 percent. A 30 percent disability rating is appropriate when there is 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, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. The next higher rating of 50 percent 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent 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 work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent 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; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to 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). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the evaluation must be 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). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Reports of psychiatric examination and treatment frequently include a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF scale includes scores ranging between zero and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). A GAF score of 51 to 60 indicates 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). A GAF score of 61 to 70 indicates 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 with some meaningful interpersonal relationships. From September 22, 2008 The Veteran essentially asserts that his PTSD has worsened over time because he is easily irritated and provoked, isolates himself, needs to take medication for nightmares, has a poor short- and long-term memory, and sleeps with a weapon. (See transcript of April 2010 Board hearing at pp. 6-12). In a signed statement dated in August 2008, the Veteran's wife wrote that his symptoms had definitely worsened, especially his memory, anger, and personal hygiene. She also stated that he seemed more depressed and went into "a rampage over simple things." During the period of this appeal, the Veteran received treatment at the Chattanooga Vet Center, approximately once every two weeks, and went to the Chattanooga VA clinic for follow-up, such as counseling and medication. A September 22, 2008 VA mental health record noted the Veteran's admission that for about 20 years he cut down on bathing and shaving. He also reported sleeping difficulties. On examination, his mood was mildly dysphoric and anxious. He denied suicidal and homicidal ideation. A VA nurse practitioner assigned a GAF score of 51. A December 2008 VA mental health record noted that the Veteran reported continued nightmares and felt guilty that he had survived the war. On examination, his mood was mildly dysphoric and anxious. He denied homicidal or suicidal ideation. The VA nurse practitioner assigned a GAF score of 51. Vet Center treatment records dated in February 2009, July 2009, January 2010, July 2010 and January 2011 noted that the Veteran appeared less depressed than when he first sought treatment in 2006 and had less need for alcohol as a means of socialization. It was also noted that he participated in group therapy and in at least one volunteer activity. The January 2010 and July 2010 records also noted the Veteran's improved sleep. In his April 2009 VA Form 9, Substantive Appeal the Veteran stated that his PTSD symptoms were the same as noted in a previous letter, namely: "impairment in mood, thinking, judgment, symptoms of killing someone, panic and depression, neglect of personal appearance and hygiene, impairment of short and long term memory, totally forgetting to complete tasks, motivation and mood." He added that he also had "unprovoked irritability such as 'flying off the handle' at the least thing toward everyone." The Board notes that the Veteran's notation in this document of "symptoms of killing someone" was not explained; however, all relevant medical records from this period deny the Veteran has exhibited any symptoms of suicidal or homicidal ideation. An April 2009 VA mental health record revealed that the Veteran reported yelling at his wife for no reason and that he came close to road rage recently when another driver was in his way. He also said that he might have three bad dreams in a row. He also reported socializing every weekend with friends. He said they sometimes played cards or sang and that sometimes he participated and sometimes he did not. On examination, his mood was mildly dysphoric and anxious. He denied any homicidal or suicidal ideation. A GAF score of 51 was assigned by the VA nurse practitioner. A July 2009 VA mental health record noted that while the Veteran had a gun in the house it was not loaded because his wife did not like him having a loaded gun. His mood was noted a mildly dysphoric and anxious. He reported that Sertraline and Mirtazapine "keeps me calmed down." A GAF score of 61 was assigned by the VA nurse practitioner. During his April 2010 Board hearing, the Veteran testified to irritability and unprovoked lashing out at people, mostly his family but occasionally friends. He agreed with his representative that "pretty much anything" could set him off and this happened at least once a week. He also testified to self-isolation, but that he and his wife got together with friends on the weekends on a regular basis and that this did not cause any problems with his mood and anxiety. He also said that he was still having nightmares and would yell out in his sleep, but he did not remember what the nightmares were about. The Veteran also testified to hypervigilance about the house. He said that before he went to bed he would check the doors, windows, and garage door and turn on four nightlights and two lamps. For the last four years he also had a gun nearby in case anyone broke into the house. (See transcript at pp. 6-11). The Veteran also complained of short term and long term memory problems. (See transcript at p. 12). The Veteran underwent a VA mental examination in October 2010. He complained of problems with sleeping, and a bad short term memory. He said that he had bad nightmares about once a month where he woke up hollering and lashing out, but that he did not remember the content of the nightmares. He told the examiner that occasionally he got a little depressed over what is going on in the world and had thoughts of going to Washington and beating everyone with an ax but that he knew better than to do that. His wife also told him that he was rude to people at times. It also was noted that the Veteran used to have significant road rage, but in the last few years was able to control this better. The examiner also noted that the Veteran did not bathe as often as he should, which had been an issue for many years. He was prescribed Sertraline and Mirtazapine, which had no side effects. It was noted that he did not attend individual psychotherapy, but participated in group therapy. The VA examiner stated that both the medications and group therapy treatments had a fair effect. At the time of this examination the Veteran had been married for 34 years to his second wife. Their arguments centered on the Veteran's drinking, but his wife was noted as very supportive and concerned about him. The Veteran said that he had cut down on his drinking over the years and now mostly drank on the weekends, typically seven to eight beers each day. It was also noted that he had a good relationship with two grown children and had eight grandchildren. He visited family in Florida for a week every year but when irritated would sometimes go back to his hotel alone. He had a small group of close friends with whom he and his wife visited on the weekends. He also walked the mall with his wife once or twice a week and occasionally went out to eat with his wife. He had been on disability retirement from the railroad, due to carpal tunnel syndrome, since 1999. On examination, the Veteran appeared oriented to person, time, and place. He presented a clean appearance, unremarkable speech and thought process, and a normal effect. There were no delusions, hallucinations, inappropriate behavior, panic attacks, memory problems, or homicidal or suicidal thoughts. He had good impulse control and no episodes of violence. His hypervigilant checking locks and doors every night before bed was noted as obsessive or ritualistic behavior. He was mildly dysphoric at times, such as when discussing his irritations, and was not able to do the serial sevens exercise or interpret proverbs appropriately. It was also noted that he could not go to sleep without medication, but was usually able to sleep through the night. Chronic symptoms noted were: difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and an exaggerated startle response. The examiner noted, however, that the Veteran could go days or weeks without significant symptoms. He had recurring thoughts of Vietnam once a month or less, which was noted as a decrease from before. The examiner also noted that the Veteran did not get as irritable as he used to and that he said he was a lot calmer than he used to be. Diagnosis was PTSD with alcohol abuse and rule out dependence. The VA examiner noted that the Veteran's alcohol consumption, now much reduced, had contributed to his anger control problems in the past. The GAF score was given as 60. The examiner opined that there was no significant change in the Veteran's functional status since the prior VA examination in January 2008. PTSD symptoms were at a moderate to low level and were not worse since the January 2008 examination and were without additional adverse effects on his functional status. Prognosis was fair for further psychiatric improvement. The examiner noted that the Veteran had shown improvement over the years and appeared to be committed to treatment. The VA examiner also opined that the Veteran's profile showed deficiencies in occupational and social impairment, due to his PTSD symptoms, in judgment, thinking, family relations, and mood. However, the examiner also opined that the Veteran's irritability, which affected his judgment and mood, had not worsened since the last VA examination. The Board finds that the Veteran's PTSD, for the period from September 22, 2008, is manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as: irritability, sleep impairment, depressed mood, and hypervigilance. The evidence of record does not show that the Veteran's PTSD symptoms were reflective of the criteria for the next higher rating of 50 percent, which requires occupational and social impairment with reduced reliability and productivity. While the Veteran exhibited some symptoms contained in the criteria for the assignment of a 50 percent rating, such symptoms were limited to impairment of short- and long-term memory, according to the Veteran and his wife. However, the October 2010 VA examiner reported that the Veteran's remote, recent, and immediate memory were all normal. Otherwise, during the period from September 22, 2008, there was no objective evidence of the following symptoms or of analogous symptoms: difficulty in understanding complex commands; impaired judgment; impaired memory or abstract thinking; stereotyped speech; flattened affect; panic attacks more than once a week; or difficulty in establishing and maintaining effective work and social relationships. In addition, information in the claims file shows that the Veteran lived at home with his wife, socialized with neighbors on the weekend, and undertook volunteer activities at the Vet Center as part of his therapy. The record also contains subjective evidence of neglect of personal appearance and hygiene as well as obsessional rituals, both symptoms associated with a higher 70 percent rating. During his October 2010 VA examination, however, the Veteran presented as clean, neatly groomed, and appropriately dressed. In any case, the Board notes that during the period from September 22, 2008, there was no objective evidence of the following symptoms or of analogous symptoms to the criteria of a 70 percent rating: suicidal ideation; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control and violence; spatial disorientation; difficulty in adapting to stressful circumstances (including work or work like setting); and inability to establish and maintain effective relationships. The Board finds that the symptomatology described in the October 2010 VA examination, and in the VA medical records and Vet Center records found in the claims file for this time period, is more consistent with the rating criteria for a 30 percent rating than for any higher rating. The October 2010 VA examiner reported that the Veteran's PTSD symptoms were moderate or low level and that the Veteran showed improvement over his earlier VA examination in January 2008. The GAF score of 60 reflected moderate symptoms. The examination report highlighted symptoms such as sleep impairment and irritability which the Board finds are more relevant to the criteria noted above that support a 30 percent rating. The October 2010 VA examiner found that the Veteran's profile showed occupational and social impairment with deficiencies in most areas, which technically matches the regulatory criteria for a 70 percent disability rating. However, this result would be inconsistent with the Veteran's symptomatology reported in the October 2010 examination and inconsistent with the examiner's observation of the Veteran's improvement from the time of the January 2008 examination to the time of the October 2010 examination. The October 2010 VA examiner recognized that the Veteran's symptoms showed deficiencies in judgment, thinking, family relations, and mood in finding occupational and social impairment with deficiencies in most areas. However, the examples the examiner cited in explaining this part of the report essentially rest on the Veteran's irritability; and it was noted in discussing the Veteran's mood that his chronic irritability was not worse since the last examination. The Board notes that after the January 2008 VA examination it found on the previous appeal that the Veteran was entitled to only a 30 percent disability rating for the period from April 7, 2006 to September 21, 2008. As the October 2010 VA examiner reports improvement in the Veteran's condition, the Board will not award a rating in excess of the current 30 percent rating. The Board also notes that the GAF scores assigned during the period from September 22, 2008 included: a 60 from the VA examination, and two 51s and a 61 noted in VA outpatient treatment records. As noted above, 51 is on the border between moderate and serious mental symptoms, scores between 51 and 60 indicate moderate symptoms, and a score of 61 indicates only mild symptoms. In the July 2010 decision, the Board noted that the medical evidence of record showed that the Veteran's assigned GAF score was 59 on the January 2008 VA examination, and the examination report noted that it was assigned for the previous two-year time frame. For the most part, the GAF scores during the current rating period are equivalent to that 59 in the initial rating period, with the exception of the assignment of a 51 in December 2008 and April 2009. The Board notes that these were assigned by a VA nurse practitioner who later changed the Veteran's GAF score to 61 by July 2009. In contrast, a VA psychologist assigned the 59 during the January 2008 VA examination and a VA psychiatrist administered the October 2010 VA examination. Therefore, the Board is persuaded that the scores of 51 are inconsistent with the reported symptomatology of the current rating period and that the preponderance of the evidence is in line with GAF scoring that shows the Veteran evidenced moderate to mild symptoms, which are indicative of his current 30 percent rating. The Board has considered the Veteran's assertions that his PTSD disability warrants a higher rating. He is certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular disability rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). While he is competent to report that his symptoms are worse, the training and experience of medical personnel makes the medical findings found in Vet Center treatment notes and the latest VA examination more probative as to the extent of the disability. See Cromley v. Brown, 7 Vet. App. 376, 379 (1995). Consideration has been given to assigning a further staged rating for this claim; however, at no time during the time period now on appeal has the Veteran's PTSD symptoms warranted the assignment of a rating higher than has been herein assigned or affirmed. See Fenderson, 12 Vet. App. at 126. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The preponderance of the evidence supports the continuation of the Veteran's initial rating of 30 percent for the period from September 22, 2008 to the present. TDIU As noted in the Introduction, the Board found that the issue of a TDIU was raised by the record in the Veteran's appeal for a higher rating for his service-connected PTSD. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As such, the TDIU claim is part and parcel of the Veteran's higher rating claim for his service-connected PTSD. Laws and Regulations Total disability means that there is present an impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. A substantially gainful occupation is "employment at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the Veteran resides" or "an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the Veteran's earned annual income." See VA Adjudication Procedure Manual, Part IV.ii.2.F.24.d., and Faust v. West, 13 Vet. App. 342, 356 (2000), respectively. A Veteran is determined unable to engage in a substantially gainful occupation when jobs are not realistically within his physical and mental capabilities. Moore v. Derwinski, 1 Vet. App. 356, 359 (1991) (citing Timmerman v. Weinberger, 510 F.2d 439, 442 (8th Cir. 1975)). In making this determination, consideration may be given to factors such as the Veteran's level of education, special training, and previous work experience, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Two different means exist to determine whether a Veteran is totally disabled. The Schedule for Rating Disabilities provides for a finding of total disability to be made on an objective basis. A Veteran is considered totally disabled if his service-connected disability is, or combination of service-connected disabilities are, rated at 100 percent. 38 C.F.R. § 3.340(a)(2). Even if the Veteran is less than 100 percent disabled, he still will be considered totally disabled if he satisfies two requirements. 38 C.F.R. § 4.16(a). First, the Veteran must meet a minimum percent rating. If he has one service-connected disability, it must be rated at 60 percent or more. If he has two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be 70 percent or more. Second, the Veteran must be found to be unable to secure and follow a substantially gainful occupation as a result of his service-connected disability or disabilities. Id. VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background and Analysis In this case, the Veteran is currently service connected for six disabilities: for residuals of small cell carcinoma of the lung with a 30 percent disability rating; for PTSD with a 30 percent disability rating; for coronary artery disease, status post myocardial infarction and angioplasty, with a 30 percent disability rating; for diabetes mellitus, type II, with a 10 percent disability rating; for peripheral neuropathy of the left lower extremity secondary to diabetes with a 10 percent disability rating; and peripheral neuropathy of the right lower extremity secondary to diabetes with a 10 percent disability rating. His combined evaluation for compensation is 80 percent. While the Veteran does not have a single disability rated at 40 percent and it does not appear at first glance that the requisite percentage standards for consideration of a TDIU for multiple disabilities under 38 C.F.R. § 4.16(a) are met, disabilities resulting from a common etiology or a single accident, or from multiple injuries incurred in action, or from multiple disabilities incurred as a prisoner of war, may be considered on a combined basis for the purposes of establishing one 60 percent disability, or one 40 percent disability rating. 38 U.S.C.A. § 4.16(a)(1). Therefore, with application of the aforementioned provision in mind, the Board finds that the Veteran's six service-connected disabilities all arise from his service in Vietnam, including exposure to herbicides, and thus all result from a common etiology. The Board notes that these disabilities met the criteria for presumptive service condition for exposure to herbicides in the Republic of Vietnam as follows: carcinoma of the lung at 30 percent; coronary artery disease at 30 percent; diabetes mellitus at 10 percent; and for peripheral neuropathy of the lower extremities secondary to diabetes at 10 percent. Therefore, the Board finds that all of these disabilities may be combined and form the basis for the establishment of a disability rated as at least 60 percent disabling under 38 C.F.R. § 4.25, for purposes of a TDIU as having a common etiology. Thus, as the Veteran has one disability rated at 60 percent, he clearly meets the minimum percent rating requirement of 38 C.F.R. § 4.16(a). Consequently, the schedular standards for consideration of a TDIU under 38 C.F.R. § 4.16(a) are met. The remaining question before the Board, therefore, is whether the Veteran is unemployable by reason of his service-connected disabilities alone, taking into consideration his educational and occupational background. The fact that a Veteran is unemployed is not enough. The question is whether his service-connected disorders without regard to his nonservice-connected disorders or lack of work skills or advancing age made him incapable of performing the acts required by employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). The record reflects that the Veteran is currently 67 years old. He completed high school with a general equivalency degree while in the service, and told the January 2008 VA mental examiner that he also completed a year of business school. He previously worked delivery for a pharmacy and worked 27 years for a railroad as a pipefitter before he retired in December 1999. During his VA mental examinations and his April 2010 Board hearing, the Veteran noted that he was retired. He told the October 2010 VA mental examiner that he retired from the railroad because of carpel tunnel syndrome as he could no longer hold the tools and kept dropping them. In addition to his service-connected disabilities, the record shows that the Veteran has several non-service connected conditions, to include: hypertension, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), and hearing loss. As noted above, the Veteran underwent a VA mental examination in October 2010. The examiner noted that while the Veteran had shown improvement over the years and appeared to be committed to treatment, it was the examiner's opinion that the Veteran's profile showed deficiencies in occupational and social impairment in most areas, such as judgment, thinking, work, and mood ,due to his irritability. In light of the evidence, and affording the Veteran the benefit of the doubt, the Board finds that the Veteran is not capable of securing and following a substantially gainful occupation as a result of his service-connected disabilities. There is no evidence that the Veteran's nonservice-connected disorders affect his ability to obtain and maintain employment or render him unemployable, except for the notation that he retired from the railroad in 1999 due to carpal tunnel syndrome. However, the evidence of record suggests that the Veteran's six service-connected disabilities, coupled with consideration of his limited educational background and limited work experience, preclude him from securing and following substantially gainful employment. The medical and lay evidence suggests that the combination of all his service-connected disabilities - PTSD, residuals of lung cancer, coronary artery disease, diabetes, and peripheral neuropathy of the lower extremities - operate as an occupational impairment. Though the claims file does not as yet contain the opinion of a VA examiner to the effect that one of the Veteran's service-connected disabilities precludes his gainful employment, the Board, resolving all reasonable doubt in the Veteran's favor, will find that it is at least as likely as not that the Veteran's service-connected disabilities, considered together as a whole, preclude the Veteran from obtaining and maintaining substantially gainful employment. The Board notes that it is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). In this case, given the Veteran's combination of service-connected disabilities, especially his coronary artery disease, residuals of lung cancer, PTSD, and peripheral neuropathy, he would likely have difficulty working again on the railroad as a pipefitter. Moreover, there is no indication from the record that he has any previous work experience or training outside of that trade. It thus appears that the Veteran has no specific skills to re-enter the work force at a job that would not involve some type of manual labor and implicate his lung, heart, diabetes, and PTSD disabilities. In addition to his service-connected disabilities, the Veteran also suffers from the other diseases noted above. But even apart from these nonservice-related disorders, the lay and medical evidence of record indicates that he would most likely be unable to secure or maintain substantially gainful employment due alone to his service-connected disabilities. In other words, even if his nonservice-connected disorders were not present, he still would be unable to obtain or maintain substantially gainful employment because of the severity of his PTSD, coronary artery disease, and the residuals of his lung cancer and diabetes disabilities considered together. Indeed, as mentioned, the service-connected disabilities related his exposure to herbicides in Vietnam may be rated together as a single 60 percent disability. As the Veteran has many disabilities, both service-connected and not, there can be no doubt that further inquiry could be undertaken with a view towards development of the TDIU aspect of this claim. However, under the "benefit-of- the-doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). The Board is of the opinion that, at a minimum, this matter is at the point of equipoise. On the one hand, the October 2010 VA examiner opined that the Veteran's current PTSD symptoms reflected occupational and social impairment resulting in deficiencies in most area. On the other hand, no VA examiner has yet found that any one of the Veteran's six service-connected disabilities, alone or in combination, would render him unable to secure or follow a substantially gainful occupation. In addition, the RO/AMC has not obtained an opinion from the Under Secretary for Benefits or the Director of the Compensation and Pension Service on whether the Veteran was entitled to an extra-schedular disability rating for any of his service-connected disabilities. While there is evidence reflecting that the Veteran has nonservice-connected disabilities that may contribute to his unemployability, overall, the evidence strongly suggests that the Veteran's service-connected disabilities, alone and in combination with one another, are significant enough in their own right to preclude him from obtaining substantially gainful employment. Therefore, based on its review of the relevant evidence, and giving the benefit of the doubt to the Veteran, the Board finds that it is as likely as not that the Veteran is precluded from work due to his service-connected disorders. As such, a total disability rating based upon individual unemployability is warranted. ORDER Entitlement to a rating in excess of 30 percent for PTSD, for the period from September 22, 2008, is denied. Entitlement to a total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) is granted, subject to the laws and regulations governing the award of benefits. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs