Citation Nr: 1433038 Decision Date: 07/23/14 Archive Date: 07/29/14 DOCKET NO. 09-21 742 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a skin condition, other than dermatophytosis of bilateral toenails, to include as due to herbicide exposure. 2. Entitlement to a total disability evaluation based on individual unemployability due to service connected disabilities (TDIU) prior to January 21, 2011. REPRESENTATION Veteran represented by: Robert W. Legg, Esq. ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran had active military service from October 1965 to August 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2003 and February 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In January 2007, the Board denied the claim for service connection for a skin condition; however, in a July 24, 2008, order, the United States Court of Veterans Appeals remanded that decision back to the Board for development consistent with a Joint Motion for Remand. In January 2009 the Board remanded the claim for additional development. A rating decision in June 2009 granted service connection for dermatophytosis of bilateral toenails. However, as the record shows that the Veteran may have other skin disorders affecting different areas of the Veteran's body for which service connection may be warranted, and as the Veteran continued his appeal for service connection for a skin disorder, other than dermatophytosis of bilateral toenails, to include as due to herbicide exposure, the issue has been recharacterized as noted on the title page of this decision. In a September 2011 rating decision, the RO awarded the Veteran a 100 percent schedular evaluation for posttraumatic stress disorder (PTSD) effective January 21, 2011. In Bradley v. Peake, the Court held that there could be a situation where a veteran has a schedular total rating for a particular service-connected disability, and could establish a TDIU rating for another service-connected disability in order to qualify for Special Monthly Compensation (SMC) under 38 U.S.C. § 1114(s) by having an "additional" disability of 60 percent or more ("housebound" rate). See Bradley v. Peake, 22 Vet. App. 280 (2008) 38 U.S.C.A. § 1114(s). Thus, Bradley made it such that even with the assignment of a total schedular rating, the issue of TDIU was potentially not moot. However, having reviewed Bradley, the Board concludes that the facts of that case are sufficiently differentiable from the facts of this case such that the holding in Bradley is inapplicable and the Veteran's TDIU claim is in fact moot. Specifically, in Bradley, the Veteran was in receipt of a 100 percent schedular rating for individual service-connected disabilities other than his PTSD. However, in this case, from January 21, 2011, the Veteran is only in receipt of a combined 40 percent for service connected disabilities other than PTSD. Therefore, the grant of a 100 percent schedular rating for PTSD moots the TDIU issue from the date where the 100 percent rating became effective. A veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Therefore, the Veteran's TDIU claim remains on appeal for the period prior to January 21, 2011, in which a 100 percent scheduler evaluation was not in effect. The Board has rephrased the issue accordingly. In December 2012, the Board remanded the Veteran's claims. The agency of original jurisdiction (AOJ) continued the previous denial of the claims in a May 2014 supplemental statement of the case (SSOC). Accordingly, the Veteran's VA claims folder has been returned to the Board for further appellate proceedings. The Board has reviewed the Veteran's claims folder as well as the record maintained in the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS). FINDINGS OF FACT 1. The Veteran's currently diagnosed skin condition other than dermatophytosis of the bilateral toenails, in particular actinic keratosis with skin rash, is not related to his military service, to include exposure to herbicides. 2. Prior to January 21, 2011, the Veteran met the percentage requirements for TDIU, as he had a single service-connected disability rated at 60 percent or more, specifically PTSD rated at 70 percent disabling; he is also rated 20 percent disabling for diabetes mellitus, type II, 10 percent disability for peripheral neuropathy of the right lower extremity, and 10 percent disabling for peripheral neuropathy of the left lower extremity which stem from a common etiology. 3. Prior to January 21, 2011, the Veteran's service-connected PTSD and peripheral neuropathy of the right and left lower extremities were shown to preclude him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. Entitlement to service connection for a skin condition other than dermatophytosis of the bilateral toenails, to include as due to herbicide exposure is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. Prior to January 21, 2011, the criteria for entitlement to TDIU are met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to service connection for a skin condition, other than dermatophytosis of bilateral toenails, as well as entitlement to TDIU. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. Stegall concerns As alluded to above, in December 2012, the Board remanded these claims and ordered the AOJ to obtain outstanding VA treatment records and provide the Veteran with a VA examination for his skin condition. The Veteran's claims were then to be readjudicated. Pursuant to the Board's remand instructions, outstanding VA treatment records have been obtained and associated with the claims folder. Additionally, the Veteran was afforded a VA examination for his skin condition in May 2013 and a report of the examination was associated with his claims folder. The Veteran's claims were readjudicated via the May 2014 SSOC. Accordingly, the Board's remand instructions have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. Duties to Notify and Assist VA has a duty to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. This notice must specifically inform the claimant of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). In letters mailed to the Veteran in May 2003 and November 2009, VA satisfied this duty. Although the November 2009 VCAA letter was provided after the initial adjudication of the skin condition claim, the Board finds that the Veteran has not been prejudiced by the timing of this letter. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claim, most recently in the May 2014 SSOC. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. VA also has a duty to assist a claimant in the development of his claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2013). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims. There is no reasonable possibility that further assistance would aid in substantiating the claims. The pertinent evidence of record includes the Veteran's statements, service treatment records, photographs, Social Security Administration (SSA) records, as well as VA and private treatment records. The Veteran was afforded a VA examination for his skin condition in May 2013 and was afforded VA examinations pertaining to employability due to service connected disabilities in January 2010. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his claims folder, reviewed his past medical history, documented his current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2013); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2013). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. He has retained the services of an attorney. He has not requested the option of testifying at a personal hearing. Accordingly, the Board will proceed to a decision. Service connection for a skin condition other than dermatophytosis of bilateral toenails The Veteran contends that he has a skin condition other than dermatophytosis of the bilateral toenails that is related to his military service, in particular his exposure to herbicides during service in Vietnam. Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2013). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). The Board initially notes that the medical evidence of record documents a current diagnosis of a skin condition other than dermatophytosis of the bilateral toenails, in particular actinic keratosis with skin rash. See, e.g., the May 2013 VA examination report. Therefore, the first element of direct service connection is established, that of a current diagnosis. With regard to element (2), evidence of in-service disease or injury, the Veteran's service treatment records show no complaints, findings or diagnosis of a skin disorder. His separation examination in August 1967 noted that his skin was evaluated as clinically normal and on contemporaneous self-report the Veteran indicated that he did not have any skin diseases. However, the Board concedes the Veteran's in-service exposure to Agent Orange. Of particular importance in this regard is the fact that service personnel records confirm the Veteran's service in the Republic of Vietnam. His exposure to herbicides is, therefore, presumed. See 38 U.S.C.A. § 1116(f). Evidence of in-service injury is therefore satisfied. The Board notes that pursuant to Section 3 of the Agent Orange Act of 1991, Pub. L. No. 102-4, 105 Stat. 11, the Secretary of Veterans Affairs (Secretary) entered into an agreement with the National Academy of Sciences (NAS) to review and summarize the scientific evidence concerning the association between exposure to herbicides used in Vietnam and various diseases suspected to be associated with such exposure. The NAS was to determine, to the extent possible, whether there was a statistical association between the suspect disease and herbicide exposure, taking into account the strength of the scientific evidence and the appropriateness of the methods used to detect the association; the increased risk of disease among individuals exposed to herbicides during the service in the Republic of Vietnam during the Vietnam era; and whether there is a plausible biological mechanism or other evidence of a causal relationship between herbicide exposure and the suspect disease. The NAS was required to submit reports of its activities every two years. The Secretary, under the authority of the Agent Orange Act of 1991 and based on studies by the NAS, has determined that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41,442-449, and 61 Fed. Reg. 57,586-589 (1996); Notice, 64 Fed. Reg. 59,232-243 (Nov. 2, 1999); Notice, 67 Fed. Reg. 42,600-608 (June 24, 2002); Notice, 72 Fed. Reg. 32,395-407 (June 12, 2007); 74 Fed. Reg. 21,258-260 (May 7, 2009). According to 38 C.F.R. § 3.309(e) (2013), the Veteran's diagnosed skin condition, actinic keratosis or any other diagnosed rash, is not one of the listed diseases as presumptively related to herbicide exposure. Therefore, actinic keratosis may not be presumed to be related to herbicide exposure. Despite the lack of presumptive service connection, service connection based on direct causation may still be established pursuant to Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Turning to crucial element (3), nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record is against a finding that the Veteran's current skin condition other than dermatophytosis of the bilateral toenails is related to his military service. Specifically, the Veteran was afforded a VA examination in May 2013. After examination of the Veteran and review of his claims folder, to include his exposure to herbicides during service and the Veteran's report of rashes on his chest, arms, and other parts of his body following discharge from service, the VA examiner diagnosed the Veteran with actinic keratosis and concluded that it is less likely than not (less than 50 percent probability) that the Veteran's actinic keratosis is related to military service. The VA examiner's rationale for his conclusion was based on his review of diseases associated with exposure to herbicides and his finding that hives, skin rashes, and actinic keratosis were not mentioned. Furthermore, he noted no documented skin condition in the Veteran's service treatment records as well as the Veteran's postservice treatment for skin rashes and hives which resolved with medication. Moreover, he noted the absence of many years between the Veteran's postservice treatment for the skin condition and his discharge from service. The May 2013 VA examination report was based upon thorough examination of the Veteran and analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. Additionally, the VA examiner considered the Veteran's in-service exposure to herbicides, and determined that his exposure did not cause his current skin condition. The Veteran has not submitted a medical opinion to contradict the VA examiner's opinion. As was explained in the VCAA section above, the Veteran has been accorded ample opportunity to present competent medical evidence in support of his claim. He has failed to do so. See 38 U.S.C.A. § 5107(a) (West 2002) [it is the claimant's responsibility to support a claim for VA benefits]. As further evidence against the claim, the Board reiterates the determination by the Secretary, under the authority of the Agent Orange Act of 1991 and based on studies by the NAS, that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41,442-449, and 61 Fed. Reg. 57,586-589 (1996); Notice, 64 Fed. Reg. 59,232-243 (Nov. 2, 1999); Notice, 67 Fed. Reg. 42,600-608 (June 24, 2002); Notice, 72 Fed. Reg. 32,395-407 (June 12, 2007); 74 Fed. Reg. 21,258-260 (May 7, 2009). Crucially, the Veteran's skin condition other than dermatophytosis of the bilateral toenails, to include actinic keratosis, is not one of the listed conditions warranting a presumption of service connection. As such, the evidence (including the Secretary's determination based on the NAS's findings) indicates a non-relationship. The Board finds that the report of the NAS is of great probative value in evaluating the Veteran's claim. Its conclusions are based on nationwide, peer-reviewed studies conducted over time with specific focus on the veteran population. The evidence of record does not contradict the findings. Therefore, the Board finds that the evidence does not support a nexus between the Veteran's service and his current actinic keratosis diagnosis with skin rash. In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board notes that the Veteran, while entirely competent to report his symptoms both current and past, has presented no clinical evidence of a nexus between his skin condition other than dermatophytosis of the toenails and his military service, to include herbicide exposure. The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to his military service. That is, the Veteran is not competent to opine on matters such as the etiology of his current skin condition. Such opinion requires specific medical training in the field of dermatology and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has the medical training in the field of dermatology to render medical opinions, the Board must find that his contention with regard to a nexus between his skin condition and military service to be of no probative value. See 38 C.F.R. § 3.159(a)(1) (2013) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. Accordingly, the statements offered by the Veteran in support of his own claims are not competent evidence of a nexus. The Board notes that it is aware of the provisions of 38 C.F.R. § 3.303(b), relating to chronicity and continuity of symptomatology in establishing service connection. However, the Federal Circuit has held that section 3.303(b) applies only to those chronic conditions specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran's actinic keratosis with skin rash is not such a listed disease entity. Therefore, establishment of service connection on the basis of continuity of symptomatology is not warranted as to this claim. Accordingly, element (3) is not met, and the Veteran's claim fails on this basis. In conclusion, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a skin condition other than dermatophytosis of the bilateral toenails. The benefit sought on appeal is accordingly denied. Entitlement to TDIU prior to January 21, 2011 Total disability ratings for compensation may be assigned where the Schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Substantially gainful employment means, essentially, that the work provides income above the poverty level established by the United States Department of Commerce, without benefit of protected family employment or a sheltered workshop. 38 C.F.R. § 4.16(a). Marginal employment is not considered substantially gainful employment. 38 C.F.R. §§ 3.340, 4.16(a). VA must consider a Veteran's service-connected disabilities, employment history, educational and vocational attainment and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). Age, however, is not a factor for consideration. 38 C.F.R. § 4.19. Basic eligibility for TDIU is established where there is one disability rated 60 percent or more, or multiple disabilities rated at least a combined 70 percent, with one disability rated at least 40 percent. 38 C.F.R. § 4.16(a). Prior to January 21, 2011, the Veteran was rated 70 percent disabling for PTSD, 20 percent disabling for diabetes mellitus, 10 percent disabling for peripheral neuropathy of the right lower extremity, and 10 percent disabling for peripheral neuropathy of the left lower extremity. The Board notes that the Veteran's diabetes and peripheral neuropathy of the right and left lower extremities arise from a common etiology, specifically herbicide exposure. In any event, as the Veteran has a disability rated at least 60 percent disabling (PTSD), he meets the basic Schedular eligibility requirement. The Veteran contends that his PTSD and physical conditions, to include his diabetes and peripheral neuropathy of the right and left lower extremities, render him unable to obtain substantially gainful employment. He is a high school graduate and has some college education. He last worked in 1999 for an insurance company in the sales department. Based on a thorough and comprehensive review of the evidence of record, resolving all doubt in favor of the Veteran, the Board finds that prior to January 21, 2011, the Veteran is shown to be unable to secure or follow a substantially gainful occupation due to service-connected disabilities, in particular his peripheral neuropathy of the right and left lower extremities and his PTSD. Specifically, the Veteran was afforded a VA examination for his diabetes and peripheral neuropathy in January 2010. With regard to his peripheral neuropathy of the right and left lower extremities, the Veteran reported tingling, burning, soreness, and numbness to both of his feet and legs. He also noted that lifting, carrying, and moving heavy objects as well as digging the ground and climbing up and down ladders aggravated his bilateral leg condition. Further, prolonged periods of walking, standing, and sitting aggravated the bilateral leg condition. Upon physical examination, the VA examiner reported that the Veteran was well-built and well-nourished. However, the Veteran was not able to walk on his toes and heels and could not perform tandem walking. Sensory was diminished to pain, light touch, temperature, and vibration to both of his lower extremities. Ankle and knee jerks were 2+ bilaterally and equal. Muscle strength was 5/5. The examiner noted that the Veteran's diabetes was well controlled with current regimen, and that it had no effect on his activities of daily living, transfer, and ambulation. Therefore, it did not impact physical or sedentary employment. However, based on symptomatology discussed above, the Veteran's neuropathy of the lower extremities impacted his physical and sedentary employment. Additionally, the Veteran was afforded a VA psychological examination in January 2010. He reported problems with his second wife since 1989 which were related to his lack of energy, lack of motivation, and lack of interest in activity. He maintained contact with one of his two daughters, although when he was with his daughter, he was withdrawn from conversation and wished to be somewhere alone. He continued to have no social relationships and no interest in doing so as he did not trust others. He spent the majority of his time sitting in his recliner with a blanket ruminating over events from his service and current problems in his life. The examiner reported that the Veteran's psychofunctional functioning was poor. Interpersonal deficits appeared to be related to loss of interest, motivational disturbance, hypervigilance, and withdrawal from others. Low level of activity appeared to be related to depressed mood, ruminations, withdrawal from others, motivational disturbance, loss of energy, and loss of interest in activity. Neglect of tasks appeared to be related to personal appearance which may also be related to depressive symptoms. The Veteran reported that his PTSD has no effects on toileting or self-feeding; moderate effects on bathing and dressing; and severe effects on household chores, grooming, shopping, sports, traveling, driving, and other recreational activities. With regard to occupational functioning, the Veteran reported difficulty concentrating at work, sometimes forgetting to complete tasks. He also had problems with productivity due to motivational issues. He was afraid of rejection and problematic interactions as an insurance salesman. This inhibited his motivation to go to homes and attempt to sell, suggesting a mismatch of personality style and work type. The examiner noted that it appeared that occupational difficulties related to mental health issues have primarily been related to concentration. The impact of this issue was mild, but would be expected to be problematic in both physical and sedentary settings. Upon examination, the VA examiner noted that the Veteran was appropriately dressed and neatly groomed. His psychomotor activity was restless, lethargic, and tense. His speech was slow, spontaneous, clear, and coherent. His affect was blunted and appropriate. His mood was poor, although attention, orientation, judgment, insight, and thought content were normal. He evidenced circumstantial thought process. He did not have delusions, homicidal thoughts, panic attacks, episodes of violence, obsessive/ritualistic behavior, or hallucinations. However, the Veteran reported that he continues to experience mild perceptual disturbances to include feeling the presence of someone, perceiving an illusion of the presence of someone out of his peripheral vision, and hearing noises at the house. The Veteran reported sleep impairment, specifically requiring one hour to initiate sleep and then wakes intermittently throughout the night. When he wakes, he may be capable of returning to sleep, while at other times he goes downstairs to sit in a chair. He averaged four hours of sleep per night which caused daytime drowsiness and fatigue. The Veteran also reported suicidal ideation. The examiner noted that the Veteran's PTSD was moderate-severe to severe. The Board further notes that a Global Assessment of Functioning (GAF) score of 41 was assigned by the VA examiner. A GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 41-50 illustrates "[s]erious 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)." Id. To reiterate, the Board finds that the Veteran's peripheral neuropathy of the right and left lower extremities and his PTSD combined arguably precluded him from obtaining substantial and gainful employment prior to January 21, 2011. As discussed above, his symptomatology associated with his neuropathy, to include tingling, burning, soreness, and numbness to both of his feet and legs as well as lifting, carrying, and moving heavy objects and prolonged periods of walking, standing, and sitting which aggravated his condition were noted by the January 2010 VA examiner to impact both physical and sedentary employment. Moreover, his PTSD symptoms, to include lack of concentration, lack of motivation, isolation, sleep impairment, and impaired speech were noted to also impact both physical and sedentary employment. Further, his assigned GAF score of 41 during the January 2010 VA examination, reflective of serious impairment, supports a finding of an inability to maintain substantial and gainful employment. In sum, the Board concludes that entitlement to TDIU is warranted prior to January 21, 2011. ORDER Entitlement to service connection for a skin condition, other than dermatophytosis of bilateral toenails, to include as due to herbicide exposure is denied. Entitlement to TDIU prior to January 21, 2011 is granted. ____________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs