Citation Nr: 1442981 Decision Date: 09/25/14 Archive Date: 10/06/14 DOCKET NO. 10-33 218 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a dental disability. 2. Entitlement to a rating in excess of 10 percent for pseudofolliculitis barbae, to include residual scar. 3. Entitlement to a rating in excess of 50 percent for service-connected major depressive disorder and panic disorder to with agoraphobia, prior to November 1, 2011. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Megan C. Kral, Associate Counsel INTRODUCTION The Veteran had active duty service from October 1999 to March 2002. The issue of service connection for a dental disability for compensation purposes comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The issue of an increased rating for pseudofolliculitis barbae and a TDIU rating come before the Board on appeal from a December 2009 rating decision by the RO. The Veteran has also initiated an appeal of the December 2009 denial of an increased rating for service-connected major depressive disorder and panic disorder to with agoraphobia (originally claimed as an adjustment disorder). A December 2012 rating decision granted a 100 percent rating for that disorder, effective November 1, 2011. However, the issue of an increased rating for service-connected psychiatric disorder (as well as TDIU) for the period prior to November 1, 2011, remains on appeal as the Veteran was not assigned a 100 percent schedular rating for the entire appeal period. A.B. v. Brown, 6 Vet. App. 35 (1993). Further, the Board also notes that the TDIU claim for the period starting November 2011 is not moot because if VA finds that disabilities other than service-connected major depressive disorder and panic disorder with agoraphobia support a TDIU rating, an award of special monthly compensation is for consideration. See Bradley v. Peake, 22 Vet. App. 280, 292 (2008) (Congress intended a single disability be rated as total for § 1114 (s), but TDIU may be used as a basis for establishing second requirement under § 1114 (s)); Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010) (TDIU rating based upon multiple disabilities does not meet the requirement of a single disability requirement of § 1114 (s).) VA also has a "well-established" duty to maximize a claimant's benefits.). See Buie, 24 Vet. App. at 250. A hearing before the Board was scheduled for April 19, 2013; in a statement received the same day, the Veteran withdrew such request and did not appear. FINDINGS OF FACT 1. It is not shown that the Veteran has a dental disability for which compensation is payable; he is not shown to have a current dental disability which is the result of in-service trauma or disease. 2. The Veteran is in receipt of a 100 percent schedular rating for service-connected psychiatric disability as of November 1, 2011. 3. The Veteran's pseudofolliculitis barbae was not productive of any significant functional effects; the percent of exposed areas affected was less than 20 percent; and the percent of total body area affected was less than 20 percent. There was no visible or palpable tissue loss and either gross distortion or asymmetry; or there was no evidence of 2 to 3 characters of disfigurement. 4. At no time prior to November 1, 2011 was the Veteran's major depressive disorder manifested by symptoms productive of impairment greater than occupational and social impairment with reduced reliability and productivity; symptoms productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood were not shown. 5. Prior to November 1, 2011, the Veteran's service-connected disabilities were not shown to be of such nature and severity as to preclude him from engaging in substantially gainful employment; since November 1, 2011, the Veteran's service-connected pseudofolliculitis barbae is not shown to be of such nature and severity as to preclude him from engaging in substantially gainful employment. CONCLUSIONS OF LAW 1. Service connection for a dental disability for compensation purposes is not warranted. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 4.150 (2013). 2. The Veteran is entitled to receive VA outpatient dental treatment. 38 U.S.C.A. §§ 1110, 1131, 1712, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.381, 17.161 (2013). 3. The criteria for a rating in excess of 10 percent for PFB have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.21,4.118, Diagnostic Codes 7800, 7806, 7813 (2013). 3. The criteria for a rating in excess of 50 percent prior to November 1, 2011 for major depressive disorder have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434 (2013). 4. A TDIU rating is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Additionally, in a claim for an increased rating, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). With regard to the claim of service connection for a dental disability, the Veteran was advised of VA's duties to notify and assist in an August 2010 letter. With regard to the claims for increased rating, the Veteran was advised of VA's duties in letters dated May and July 2009. These letters explained the evidence necessary to substantiate his claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. These letters also informed the Veteran of disability rating and effective date criteria. The Veteran has had ample opportunity to respond/supplement the record and he has not alleged that notice in this case was less than adequate. The Veteran's service treatment records (STRs), post-service treatment records (both VA and private), and Social Security Administration (SSA) records have been secured. The RO arranged for a VA psychological examination in June 2009, VA dermatology examinations in June 2009 and October 2011, and a VA dental examination in November 2006. The Board notes that the VA examination reports contain sufficiently specific clinical findings and informed discussion of the pertinent history and features of the disability on appeal to provide probative medical evidence adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide this matter, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's record with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service connection for Dental Disability Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. A disability may be service connected if shown to be of a chronic nature in service, or if not chronic, then seen in service with continuity of symptomatology demonstrated after discharge. 38 C.F.R. § 3.303(b). Disorders diagnosed after discharge may still be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To substantiate a claim of service connection, there must be evidence of a current disability; evidence of incurrence or aggravation of a disease or injury in service; and evidence of a nexus between the claimed disability and the disease or injury in service. See Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Essentially, the Veteran seeks service connection for the purpose of receiving VA outpatient dental treatment: "I am unable to receive essential dental treatment." See VA Form 9 dated July 31, 2010. See 38 C.F.R. §§ 3.381, 4.150; see also 64 Fed. Reg. 30,392 (June 8, 1999). Under the holding in Mays v. Brown, 5 Vet. App. 302, 306 (1993), a claim for service connection is also considered a claim for VA outpatient dental treatment, so the Board will consider his entitlement to service connection for both compensation and outpatient dental treatment. Under VA regulations, compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Service treatment records show that the Veteran was treated for caries of tooth #2 in July 2000 which would later result in a root canal. Additionally, all four wisdom teeth were surgically extracted in August 2000. Dental records show a bridge was placed, but then fell out in April 2001. Records indicate the Veteran was asymptomatic and the bridge was restored with cement. Post-service dental records show that in September 2005, tooth #2 was extracted. Additionally dental records show the Veteran was treated for a cleaning, and while other restoration work was discussed, the work was not scheduled nor performed. On November 2006 VA dental examination, the Veteran reported that he had extensive dental restoration performed in service. He reported that he had a cavity, and pointed to where tooth #2 used to be, and that over a period of time several fillings were placed that fell out, and a root canal was started. He reported that the root canal was not completed until he relocated to Alaska, and that a final restoration was never completed. Following separation from service, the tooth reportedly became infected which led to the need for its extraction. The Veteran reported that tooth #1 was also infected and required extraction. He additionally complained that cement which held the bridge on remained on his teeth and wanted it removed. The Veteran stated that he wanted VA to take care of his teeth because he had lost several and wanted to maintain his remaining dentition. On examination, the examiner noted the Veteran's jaw opened fully, without clicks or pops. Crepitus was reported on the right side with closing. There was no history of lock jaw. The lower jaw had no deviation upon opening. Jaw and temporomandibular joints were normal in appearance. The Veteran was able to function satisfactorily; no acute situation exists. No swelling, inflammation or pain were reported. Full range of masticatory motion, without loss of motion was noted. It was noted that the Veteran chewed on the left side because of missing teeth on the right side. The examiner noted the Veteran was missing several upper and lower molar and premolar teeth, without wearing dentures to replace the missing teeth. The examiner noted that the upper missing teeth could be replaced by removable partial dentures and the lower could be replaced by a bridge. No loss of bone or tissue was reported. The examiner concluded that the Veteran had lost two upper posterior teeth due to extractions when teeth became symptomatic. There was no history of mandibular or maxillary jaw fractures. The Veteran argues that the root canals performed in service should be considered in-service dental trauma, which caused missing teeth and teeth and gum-line pain. Considering the evidence in light of the above, the Board finds that the Veteran does not have a compensable dental disability. Notably, he has not submitted any competent evidence showing that he suffers from any of the disabilities included under 38 C.F.R. § 4.150. Based upon the foregoing, the Board concludes that there is no basis in the law for the award of service-connected VA disability compensation for the Veteran's current dental condition. He is not eligible for VA compensation as his current dental condition does not fall under the categories of compensable dental conditions set forth in 38 C.F.R. § 4.150. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Having determined that the Veteran is not eligible for service-connected compensation benefits, the Board must now consider whether service connection may be established solely for the purpose of outpatient treatment. The determination of whether service connection may be established for the purpose of outpatient dental treatment is based on the criteria set forth under 38 C.F.R. § 3.381, which provides that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment. In determining service connection, the condition of teeth and periodontal tissues at the time of entry into active duty will be considered. Treatment during service, including filling or extraction of a tooth, or placement of a prosthesis, will not be considered evidence of aggravation of a condition that was noted at entry, unless additional pathology developed after 180 days or more of active service. See 38 C.F.R. § 3.381(c). The law also provides classes of eligibility for VA dental treatment, defining the circumstances under which treatment may be authorized. These are designated Classes I, II, II(a), II(b), II(c), IIR, III, IV, V, and VI. 38 C.F.R. § 17.161. Class IV treatment pertains to veterans "whose service-connected disabilities are rated at 100% by schedular evaluation." Such veterans, as here, "may be authorized any needed dental treatment." 38 C.F.R. § 17.161. After careful review of the evidence, the Board finds that the Veteran is eligible for VA Class IV dental treatment. As noted above, the Veteran's service-connected disabilities have been rated 100% by schedular evaluation since November 1. 2011. The Veteran meets the requirements under 38 C.F.R. § 17.161 for service connection for the limited purpose of receiving VA treatment. Consequently, service connection for purposes of dental treatment only is warranted. Increased Ratings Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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). Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings may be appropriate in an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Pseudofolliculitis barbae The specific diagnosis of pseudofolliculitis barbae does not have its own diagnostic code; it is rated by analogy under Code 7813 (for dermatophytosis of the beard area), which provides for rating as disfigurement of the head, face, or neck (Code 7800), scars (Codes 7801-7805), or dermatitis (7806), depending upon the predominant disability. The RO has determined that the predominant disability is akin to dermatitis (7806) and evaluated the Veteran's pseudofolliculitis barbae as such. See 38 C.F.R. § 4.20. The Board notes that the criteria for rating skin disorders were revised effective October 23, 2008 (while this appeal was pending), and that the Veteran is entitled to review of the revised criteria if he so requests. However, the regulatory changes apply to diagnostic Codes 7801-7805. Inasmuch as the instant claim involves application of Codes 7806 and 7800 (neither of which was amended), and because the pathology required for rating under Codes 7801-7805 (deep and nonlinear scars, scars involving an area of 144 square inches or more, more than 2 unstable or painful scars, or scars involving not otherwise recognized disabling effects), are not shown, further discussion of the regulatory criteria revisions is not necessary. Code 7806 provides for rating dermatitis or eczema based on the percentage of the entire body or exposed areas affected or systemic therapy. Dermatitis or eczema that involves at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period, is rated 10 percent disabling. Dermatitis or eczema that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period, is rated 30 percent disabling. Dermatitis or eczema that involves more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period, is rated 60 percent disabling. 38 C.F.R. § 4.118. Code 7806 also provides that, alternatively, the disorder may be rated as disfigurement of the head, face, or neck under Code 7800. Under Code 7800, a 10 percent rating is warranted where there is one of the eight characteristics of disfigurement. A 30 percent rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. The 8 characteristics of disfigurement referred to in Code 7800 are: a scar five or more inches (13 or more centimeters) in length; a scar at least one-quarter inch (0.6 centimeters) wide at the widest part; the surface contour of the scar is elevated or depressed on palpation; the scar is adherent to underlying tissue; the skin is hypo- or hyper- pigmented in an area exceeding six square inches (39 square centimeters); the skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters); there is underlying soft tissue missing in an area exceeding six square inches (39 square centimeters); and, the skin is indurated and inflexible in an area exceeding six square inches (39 square centimeters). Id., Note 1. On June 2009 VA examination, the examiner noted that the skin disease involved areas that were exposed to the sun, including the Veteran's face. However, it did not include the hands, neck, and head. The Veteran reported the main areas of concern include cheeks, beard, mustache, and neck. Due to this condition, he reports constant exudation of the face and back, itching face and back, shedding face and back, and crusting face and back. There was no ulcer formation. The Veteran reported using a topical skin cream three times a day and skin bleach three times a day since December 2007. He indicated that the skin creams lighten the complexion of the afflicted areas. The Veteran reported he experienced low self-esteem because of the skin condition as he avoided public areas. On examination, skin did not reveal acne, chloracne, scarring alopecia, alopecia areata, or hyperhidrosis. Pseudofolliculitis barbae was diagnosed, located on the hair growing-areas of the face and neck, with the characteristics of crusting, disfigurement, hyperpigmentation of less than six square inches, and abnormal texture of less than six square inches. There was no ulceration, exfoliation, tissue loss, induration, inflexibility, hypopigmentation, or limitation of motion. The skin lesion coverage of the exposed area is 5 percent. The skin lesion coverage relative to the whole body is 1 percent. The skin lesions were not associated with systemic disease. The examiner noted that at the time of examination, the condition was active with subjective manifestations including, bumps, oozing, crusting, and shading skins lesions over the face and neck. Objective manifestations included small nodules over the hair growing areas of the face and neck area. The effect of the condition on the claimant's daily activities is to avoid shaving and let his hair over the face and neck grow. A dermatology consultation was conducted in May 2010. The Veteran reported using benzoyl peroxide in the past, but was out of it. On examination, 3 to 4 hyperpigmented lesions were seen. No true pustule lesions were noted. The dermatologist diagnosed fairly well-controlled pseudofolliculitis barbae. The Veteran was instructed to use benzoyl peroxide gel once daily and clindamycin solution after shaving. He was also instructed to continue shaving with clippers. On October 2011 VA examination, pseudofolliculitis barbae was diagnosed. The Veteran reported that since the May 2010 dermatology consultation, the benzoyl peroxide gel and clindamycin solution became ineffective and he ran out of them. He reported having to remove ingrown hairs almost daily which leave large pores. He stated the condition was constant and affected his cheeks. He has few scars on his cheeks where hairs have been removed, and stated if he did not remove the hairs, they get infected. He reported not being able to get a job where shaving was required. The examiner noted pseudofolliculitis barbae caused scarring and disfigurement, but without skin neoplasms or systemic manifestations. Constant oral medications were noted to be used over the past 12 months (but unidentified on examination) and oral medications, to include benzoyl peroxide gel and clindamycin solution were noted to be used 6 weeks or more during the past 12 months. No debilitating or non-debilitating episodes of urticarial, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis were reported. The total area of the body affected was less than 5 percent. The total exposed area was also less than 5 percent. The Veteran reported that his condition limits employment opportunities because he would need to shave for some jobs, and shaving exacerbates the condition. The examiner noted that the Veteran had scars or disfigurement of the head, face or neck. Scars were not painful or unstable or the result of burns. An area of scars measuring 0.1 x 0.1 centimeters, numbering too many to count, was identified as slightly depressed, hyperpigmented follicular scars around the perioral area. The examiner noted that beard growth made the scars too difficult to count. Also identified were a scar of the right cheek measuring 1 x 0.5 centimeters, a scar of the left cheek measuring 1.6 x 0.5 centimeters, and a second scar of the left cheek measuring 0.6 x 0.5 centimeters. The scars of the perioral area were noted to be depressed on palpitation and hyperpigmented. The total area of hyperpigmented scars totaled 2 square centimeters. No gross distortion of facial features or tissue loss was noted. Scars did not result in a limitation of function, nor was there any muscle or nerve damage found. The examiner opined that the Veteran's scars did not limit his ability to work. At no time during the course of the appeal was the total area of the Veteran's body affected by pseudofolliculitis barbae greater than 20 percent. Notably, there is no indication of involvement beyond the facial/beard area, and that not approximating 20 percent of exposed area. Additionally, although the Veteran was prescribed oral medications, to include benzoyl peroxide gel and clindamycin solution, these medications are not evidence of systemic treatment and are not corticosteroids or other immunosuppressive drugs as are required by the regulations so as to warrant a higher evaluation. Therefore, a higher rating under Code 7806 is not warranted. 38 C.F.R. § 4.118. With respect to disfigurement under Code 7800, a higher (30 percent) rating is not warranted because there is no evidence of record showing visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features; nor is there evidence of two or three characteristics of disfigurement (as identified above). 38 C.F.R. § 4.118, Diagnostic Code 7800. Accordingly, the criteria for a rating in excess of 10 percent for pseudofolliculitis barbae are neither met nor approximated, and such rating is not warranted. Accordingly, the claim for increase must be denied. Furthermore, the Board finds that the evidentiary record presents no reason to refer the case to the Compensation and Pension Service for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b). There is no evidence of symptoms or impairment not encompassed by the schedular criteria, so as to render those criteria inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). Major Depressive Disorder prior to November 1, 2011 The General Rating Formula for Mental Disorders, including Code 9434 (for major depressive disorder), at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities. A 50 percent rating is warranted if it is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A maximum 100 percent evaluation is warranted for a total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communications; 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 or close relatives, own occupation, or own name. Id. The Board notes here that the symptoms listed in VA's general rating formula for 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 (2002). The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). According to the DSM-IV, a GAF score of 31-40 indicates some impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF score between 41 and 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). A GAF score between 51 and 60 is indicative of 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 coworkers); a GAF between 61 and 70 is indicative of 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, has some meaningful interpersonal relationships. A July 2008 treatment record notes the Veteran was feeling down, depressed, anxious, nervous and irritable. He reported not sleeping well. He denied hallucinations and suicidal or homicidal ideations. At the time the Veteran also denied counseling. He was diagnosed with adjustment disorder with panic disorder and agoraphobia. His GAF was 50. In September 2008, it was noted he had depression; his GAF was 50. Additionally VA treatment records from this time show a history of depression. On June 2009 examination the Veteran noted that his depression and anxiety began when he learned he would not have custody of his daughter. He reported trouble sleeping, feeling very anxiety ridden, getting very angry in crowds, and constant worry. On examination, his orientation, appearance, and hygiene were within normal limits. His behavior was normal with the exception that his thoughts, concentration, and speech were somewhat slowed. His affect was restricted and his mood dysphoric. Panic attacks were present or partial panic attacks were present when in crowds. No suspiciousness or delusions were reported. However, he intermittently heard mumbled voices or screams. Abstract thinking, memory and judgment were normal. He denied suicidal or homicidal ideation. Depressive disorder and panic disorder with agoraphobia were diagnosed. His GAF was 50. The examiner noted the Veteran had no difficulty in performing activities of daily living. It was noted that he had difficulty establishing and maintaining effective work, school, and social relationships; however, he has good social relationships with his current significant other and children. His anxiety and depression cause him to stay home and not go around people he does not know. The examiner noted his psychiatric symptoms cause occupational and social impairment with deficiencies in most areas, such as school, work, family, and mood. It was noted that he has difficulty in adapting to stressful circumstances, disturbances of motivation and mood. He has no difficulty understanding simple commands, and does not appear to pose a threat to himself or others. In 2010, the Veteran had infrequent mental health visits. However, on May 2010 mental health consultation the Veteran reported his primary stressors were relationship problems with his girlfriend and his long history of custody disputes. The Veteran reported feeling guilt and stress but denied suicidal or homicidal ideation and denied persistent feelings of depression. His appearance and affect were appropriate; his attitude was cooperative; his speech was fluent, relevant, and coherent; his mood was guilty and self-contemplative. There were no abnormalities with his perception or thought content, and his thoughts were linear, logical and goal-directed. Adjustment disorder was diagnosed. His GAF was 58. Brief counseling was scheduled, however the Veteran failed to show for this appointment. In September 2011, the Veteran contacted the mental health clinic requesting to return to speak to someone regarding counseling services. He denied crisis and suicidal or homicidal ideation. However, the Veteran failed to show for his scheduled appointment. The Veteran's mental health was reevaluated on November 1, 2011, which was the basis of the award of the 100 percent rating. However, prior to that date the Veteran never manifested depressive symptoms that met or approximated the criteria for the next higher (70 percent) rating. The June 2009 examination report and May 2010 treatment records note that the Veteran did not have suicidal thoughts. The June 2009 examination also noted the Veteran did not have a problem with activities of daily living, that although his speech was slow it was otherwise unremarkable; he had good judgment, insight and impulse, was oriented; was able to maintain personal hygiene, and that his memory was normal. No evidence of obsessional rituals or near continuous panic were noted. In other words, his depressive symptoms did not include most of the criteria listed for the 70 percent (or higher) rating. While the Veteran did have impairments such as difficulty sleeping, stress, and depression, these alone do not warrant a 70 percent rating, as his symptoms, taken together, are not of sufficient severity to justify a higher rating. Moreover, in May 2010, the Veteran specifically denied persistent depression. Additionally, while the June 2009 examiner noted the Veteran had difficulty establishing and maintaining effective work, school, and social relationships; it was noted that he had good social relationships with his current significant other and their children. Therefore, a higher rating based on the Veteran's inability to establish or maintain effective relationship is not warranted. During the applicable appeal period (prior to November 1, 2011), the pertinent record shows that the assigned GAF scores mostly ranged from 50 (indicating serious impairment) to 58 (indicating moderate impairment), which do not provide a separate basis for a rating in excess of 50 percent. In viewing the evidence of record in its entirety, the Board finds that at no time during the evaluation period is the Veteran's depressive disability picture presented consistent with (or approximates) the schedular criteria for a 70 percent (or higher) rating. The preponderance of the evidence is against a rating in excess of 50 percent for this period of time when all the manifestations are considered. See Mauerhan, 16 Vet. App. 436. Accordingly, the claim for increase must be denied. Furthermore, the Board finds that the evidentiary record presents no reason to refer the case to the Compensation and Pension Service for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b). The manifestations of the Veteran's depressive disorder, including anxiety, occupational and social impairments, sleep disturbance, and stress are contemplated by the schedular criteria. As such, there is no evidence of symptoms or impairment not encompassed by the schedular criteria, so as to render those criteria inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). A TDIU rating The Veteran alleges that he was unemployed since his 2002 service discharge and at most only worked two weeks at one time. The record shows that from May 2002 to March 2003 he was employed. Additionally, between October 2005 and November 2011, the Veteran was enrolled in various online courses as a full time student. The record confirms the Veteran was enrolled in courses from October 2005 to May 2006, May and June 2008, June 2009, January 2010 to December 2010, and September 2011. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16. As an initial matter, the Board notes that since November 1, 2011, the preponderance of the evidence does not show that the Veteran has service-connected disabilities other than service-connected major depressive disorder and panic disorder that would support a TDIU rating. In this regard, the Veteran's only other service-connected disability is pseudofolliculitis barbae, discussed above, and rated 10 percent throughout the appeal period. While the October 2011 examiner found that the Veteran limited in his employment in positions that required him to shave, because shaving exacerbated his pseudofolliculitis barbae, such evidence does not support a finding that his pseudofolliculitis barbae precludes him from obtaining or maintaining any gainful employment consistent with his education and occupational experience. Prior to November 1, 2011, the Veteran's service connected disabilities included: major depressive disorder with panic disorder and agoraphobia, rated 50 percent and pseudofolliculitis barbae, rated 10 percent. The combined rating is 60 percent. Therefore, he does not meet the above-cited schedular requirements for a TDIU rating in 38 C.F.R. § 4.16(a). The analysis then turns to "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For the period of time where the Veteran was either employed or enrolled as a full time student, a TDIU rating is not warranted. For the period of time prior to November 1, 2011, when the Veteran was unemployed, a TDIU rating is not warranted because on October 2006 examination, the examiner determined that although the Veteran was unemployed, it was a combination of his service-connected chronic adjustment disorders (now claimed as depressive disorder) and his chronic personality disorders that are not service-connected, that render him unemployable. The examiner specifically stated that it was not just the Veteran's service-connected disabilities that rendered him unemployable. On October 2011 examination, the examiner found that the Veteran was only limited in his employment in positions that required him to shave, because shaving exacerbated his pseudofolliculitis barbae. Additionally, Social Security Administration (SSA) records show the Veteran was denied SSA benefits on September 2008, December 2008, and September 2009 for the period between March 2002 and December 2006, finding that in consideration of the Veteran's age, education, work experience, and residual functional capacity, there were jobs that existed that he could have performed. While SSA determinations are not binding on the Board, the records relied upon to make the determination are probative evidence in consideration of the Veteran's appeal. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (observing that while SSA decisions are relevant, there are significant differences between SSA and VA recognition of disabilities and SSA decisions are not binding on VA). Therefore, prior to November 1, 2011, the overall evidence does not show that the Veteran's service-connected disabilities (major depressive disorder with panic disorder and agoraphobia, and pseudofolliculitis barbae), alone prevented his participation in substantially gainful employment. Hence, the Board finds that the preponderance of the evidence is against the claim for a TDIU rating. The benefit of the doubt doctrine does not apply; the appeal must be denied. ORDER Entitlement to service connection for a dental disability, solely for the purpose of obtaining VA outpatient dental treatment, is granted. A rating in excess of 10 percent for pseudofolliculitis barbae, to include residual scar, is denied. A rating in excess of 50 percent for service-connected major depressive disorder and panic disorder with agoraphobia, prior to November 1, 2011, is denied. A TDIU rating is denied. ____________________________________________ M.C. Graham Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs