Citation Nr: 0810496 Decision Date: 03/28/08 Archive Date: 04/09/08 DOCKET NO. 04-25 379 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a thyroid disorder, Graves' disease, to include as secondary to service-connected post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for a "stomach condition", to include as secondary to service-connected PTSD. 3. Entitlement to service connection for drug and alcohol abuse, claimed as secondary to service-connected PTSD. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). ATTORNEY FOR THE BOARD David T. Cherry, Counsel INTRODUCTION The veteran served on active duty from December 1967 to April 1970. He served in the Republic of Vietnam. This case comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. Procedural history In an October 1992 rating decision, service connection was granted for a scar as a residual of a removal of a cyst from the left upper eyelid; a noncompensable (zero percent) disability rating was assigned. In a January 1996 rating decision, service connection was granted for PTSD; a 50 percent disability rating was assigned. In a June 2003 rating decision, the RO denied the veteran's claims for service connection for Graves' disease and a stomach condition, and for TDIU. The veteran perfected an appeal of those denials. In a May 2004 rating decision, the RO denied service connection for drug and alcohol abuse. The veteran perfected an appeal of that denial. In February 2006, the Board remanded these issues to the RO for further development. In October 2007, a supplemental statement of the case (SSOC) was issued by the RO which continued the previous denials of the claims. The case is once again before the Board. In November 2007, the veteran requested a Travel Board hearing. In February 2008, the veteran was scheduled for a videoconference hearing before a Veterans Law Judge to be held in March 2008. The veteran failed without explanation to appear for that hearing. He has not since requested another hearing. Accordingly, the Board will proceed as if the hearing request had been withdrawn. See 38 C.F.R. § 20.704(d) (2007). Issue not on appeal In its February 2006 decision, the Board denied the veteran's claim for an increased disability rating for PTSD. That issue has therefore been resolved. See 38 C.F.R. § 20.1100 (2007). FINDINGS OF FACT 1. The veteran served in the Republic of Vietnam during the Vietnam era 2. The veteran has been diagnosed with Graves' disease. 3. Competent medical evidence indicates that the veteran's Graves' disease is not causally related to the veteran's military service or any incident thereof, to include presumed herbicide exposure in service. 4. The competent medical evidence of record does not support a conclusion that the veteran's Graves' disease is caused by or aggravated by his service-connected PTSD. 5. The veteran has been diagnosed with status post right hemicolectomy due to perforated diverticular disease. 6. Competent medical evidence indicates that the veteran's status post right hemicolectomy due to perforated diverticular disease is not causally related to the veteran's military service or any incident thereof, to include presumed herbicide exposure in Vietnam and symptoms in service that were diagnosed as viral enteritis. 7. The competent medical evidence of record does not support a conclusion that the veteran's status post right hemicolectomy due to perforated diverticular disease is caused by or aggravated by his service-connected PTSD. 8. The veteran has been diagnosed with a polysubstance abuse disorder involving primarily cocaine but also marijuana and alcohol. 9. The competent medical evidence of record does not support a conclusion that the veteran's polysubstance abuse disorder is caused or aggravated by his service-connected PTSD. 10. The veteran's service-connected disabilities are the following: PTSD, evaluated as 50 percent disabling; and scar as a residual of a removal of a cyst from the left upper eyelid, evaluated as zero percent disabling. A combined disability rating of 50 percent is in effect. 11. The medical and other evidence of record does not demonstrate that the veteran's service-connected disabilities, alone, render him unable to secure or follow a substantially gainful occupation, so as to render impractical the application of the regular schedular standards. CONCLUSIONS OF LAW 1. A thyroid disorder, diagnosed as Graves' disease, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116 (West 2002); 38 C.F.R. §§ 3.303, 3.3.7, 3.309 (2007). 2. A thyroid disorder, diagnosed as Graves' disease, is not proximately due to or the result of the veteran's service- connected PTSD. 38 C.F.R. § 3.310 (2007). 3. A "stomach condition", diagnosed as status post right hemicolectomy due to perforated diverticular disease, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1116 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 4. A stomach condition, diagnosed as status post right hemicolectomy due to perforated diverticular disease, is not proximately due to or the result of the service-connected PTSD. 38 C.F.R. § 3.310 (2007). 5. Polysubstance abuse is not proximately due to or the result of the service-connected PTSD. 38 C.F.R. § 3.310 (2007). 6. The criteria for entitlement to a total rating based on individual unemployability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 3.341, 4.16, 4.19 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran is seeking service connection for a thyroid disorder, a stomach condition, and drug and alcohol abuse, as well as TDIU. In the interest of clarity, the Board will initially discuss certain preliminary matters. The Board will then address the pertinent law and regulations and their application to the facts and evidence. Stegall concerns In February 2006, the Board remanded the veteran's claims to the RO for the following: to provide proper notice under the Veterans Claims Assistance Act of 2000 (the VCAA) with regard to his secondary service connection claims; to obtain records from the Social Security Administration (SSA); and to obtain VA nexus opinions. The issues on appeal were then to be readjudciated. In March 2006, the RO provided VCAA notice [this will be discussed in greater detail immediately below]. In April 2006, the RO received SSA records pertaining to the veteran. In May and June 2007, the veteran underwent VA examinations, and the VA examiners rendered medical nexus opinions. The RO readjudicated the claims in a SSOC issued in October 2007. Based on this history, the Board finds that the RO has complied with the directives of the February 2006 remand. 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]. The VCAA The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. The Board has carefully considered the provisions of the VCAA and the implementing regulations in light of the record on appeal, and for reasons expressed immediately below finds that the development of these issues has proceeded in accordance with the provisions of the law and regulations. The VCAA alters the legal landscape in three distinct ways: standard of review, notice and duty to assist. The Board will now address these concepts within the context of the circumstances presented in this case. Standard of review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of 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. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2007). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (the Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Notice The VCAA requires VA to notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided to VA that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, 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 (West 2002); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002) [a letter from VA to an appellant describing evidence potentially helpful to the appellant but not mentioning who is responsible for obtaining such evidence did not meet the standard erected by the VCAA]. Crucially, the RO informed the veteran of VA's duty to assist him in the development of his service connection claims and TDIU in letters sent to him in July 2004, March 2006, April 2006, and February 2008, which were specifically intended to address the requirements of the VCAA. The July 2004 VCAA letter informed the veteran of the evidence necessary to establish direct service connection and TDIU. The March 2006 letter informed the veteran of the evidence necessary to establish secondary service connection. Accordingly, the veteran was informed of the information and any medical or lay evidence not previously provided to VA that is necessary to substantiate the claims. As for evidence to be provided by the veteran, in the July 2004 and March 2006 letters the RO asked the veteran to identify medical evidence. Moreover, in the July 2004 and March 2006 VCAA letters, the veteran was informed that VA would provide a medical examination or obtain a medical opinion if it is necessary to make a decision on his claims. [VA examinations were conducted in May and June 2007, and medical nexus opinions were rendered by the May and June 2007 VA examiners.] In the July 2004 and March 2006 VCAA letters, the veteran was advised that VA was responsible for getting relevant records from any Federal agency, to include records from the military, VA medical centers (including private facilities where VA authorized treatment), and the Social Security Administration. The veteran was also informed that VA make reasonable efforts on his behalf to get relevant records not held by a Federal agency, including records from state and local governments, private doctors and hospitals, and current or former employers. In the July 2004 and March 2006 VCAA letters, the veteran specifically told to send any evidence in his possession that pertains to his claims. This request was open ended. The VCAA letters thus complied with the "give us everything you've got" requirement of 38 C.F.R. § 3.159(b)(1) because the letters informed the veteran that he could submit or identify evidence other than what was specifically requested by VA. In short, the record indicates that the veteran received appropriate notice under 38 U.S.C.A. § 5103 and Quartuccio. The Board is of course aware of the Court's decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), which appears to stand for the proposition that VCAA notice must be sent prior to adjudication of an issue by the RO. In this case, the claims were adjudicated in June 2003 and May 2004, prior to the July 2004 and March 2006 VCAA letters, the first VCAA letters specifically addressing these claims. However, following the issuance of the VCAA letters, the veteran was allowed the opportunity to present evidence and argument in response. Specifically, the claims were readjudicated in the SSOC issued in October 2007. Therefore, the essential fairness of the adjudication was not affected. See Sanders, supra. The veteran has pointed to no prejudice or due process concerns arising out of the timing of the VCAA notice. The Board accordingly finds that there is no prejudice to the veteran in the timing of the VCAA notice which was given with regard to the four elements of 38 U.S.C.A. § 5103 as to these claims. In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court observed that a claim of entitlement to service connection consists of five elements: (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. Because a service connection claim is comprised of five elements, the Court further held that the notice requirements of section 5103(a) apply generally to all five elements of that claim. Therefore, upon receipt of an application for a service connection claim, section 5103(a) and section 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, with respect to the service connection claims, element (1), veteran status, and element (2), existence of a disability, are not at issue. The service connection claims were denied based on element (3), relationship of such disabilities, to the veteran's service. As explained above, he has received proper VCAA notice as to his obligations, and those of VA, with respect to this crucial element regarding this claim. Moreover, the RO specifically addressed elements (4) and (5) in the April 2006 and February 2008 letters. As for the TDIU claim, elements (1), (2) and (3) are not at issue. As explained above, the veteran has received proper VCAA notice as to his obligations, and those of VA, with respect to current level of disability, element (4), in the July 2004 VCAA letter. Also, the RO specifically addressed elements (4) and (5) in the April 2006 and February 2008 letters. As for the timing of the notice of the fifth element in Dingess/Hartman, the Board again notes that the veteran was allowed the opportunity to present evidence and argument in response to the April 2006 and February 2008 VCAA letters. See, e.g., the October 2007 SSOC. Therefore, the essential fairness of the adjudication was not affected. The Board accordingly finds that there is no prejudice to the veteran in the timing of the VCAA notice as to the fifth element in Dingess/Hartman. See Sanders, supra. The veteran has pointed to no prejudice or due process concerns arising out of the timing of the VCAA notice as to the fifth element in Dingess/Hartman. While the RO provided notice as to as to Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006) in March 2006 and February 2008, in light of the subsequent Court decision in Vazquez- Flores v. Peake, No. 05-0355 (U.S. Vet. App. Jan. 30, 2008), the issue is whether more detailed notice must be provided as to the TDIU claim. The Court in Vazquez-Flores held that a notice letter must inform the veteran: (1) that, to substantiate a claim, the veteran must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity and the effect that worsening has on the claimant's employment and daily life; (2) if the veteran is rated under a Diagnostic Code that contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the notice letter must provide at least general notice of that requirement; (3) that if an increase in disability is found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from 0% to as much as 100% (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life; and (4) of examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation - e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. The Board finds that Vazquez-Flores does not apply to a TDIU claim because the schedular ratings for the veteran's service-connected disabilities are not at issue. However, assuming that Vazquez-Flores does apply to a TDIU claim, the July 2004 VCAA letter informed the veteran that the evidence must show that he is unable to secure and follow a substantially gainful occupation solely due to his service- connected disabilities. Therefore, the July 2004 VCAA letter addressed the first prong of the holding in Vazquez-Flores. The veteran's service-connected disabilities are PTSD and a scar as a residual of a removal of a cyst from the left upper eyelid. As to his PTSD, the Diagnostic Code in question pertains to specific psychiatric symptomatology, and with regard to his scar, the Diagnostic Code in question pertains to specific findings of disfigurement. The notice letters did not provide at least general notice of those requirements. However, the essential fairness of the adjudication was not affected because the veteran had actual knowledge of what was necessary to substantiate his claim for TDIU based on his service-connected PTSD. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim. Vazquez-Flores, slip op. at 12, citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007). In this case, the veteran was informed of the specific rating criteria for PTSD in a June 2003 rating decision and a May 2004 statement of the case pursuant to his then-pending claim for an increased rating for PTSD. As to the specific rating criteria for his scar, the essential fairness of the adjudication was not affected by the lack of general notice of the requirements to show a compensable rating for the service-connected scar because the veteran is not claiming that he is unemployed based on his service-connected scar of the left upper eyelid. See Sanders, supra. The veteran has pointed to no prejudice or due process concerns arising out of the lack of general notice of the requirements to show a compensable rating for the service-connected scar. The Board accordingly finds that there is no prejudice to the veteran as to the lack of general notice of the requirements to show a compensable rating for the service-connected scar. As for the third prong of the holding in Vazquez-Flores, the April 2006 and February 2008 VCAA letters informed the veteran that the rating for his disability can be changed if there are changes in his condition and that depending on the disability involved, VA will assign a rating from zero percent to as much as 100 percent. The RO stated that VA uses a schedule for evaluating disabilities that is published as title 38 Code of Federal Regulations, Part 4. The RO indicated that in rare cases, VA can assign a disability level other than the levels found in the schedule for a specific condition if his impairment is not adequately covered by the schedule. The RO indicated that it would consider evidence of the following in determining the disability rating: nature and symptoms of the condition; severity and duration of the symptoms; and impact of the condition and symptoms on employment. Accordingly, the April 2006 and February 2008 VCAA letters addressed the third prong of the holding in Vazquez-Flores. With regard to the fourth prong of the holding in Vazquez- Flores, in the February 2008 VCAA letter the RO stated that examples of evidence that you should tell us about or give to us that may affect how we assign a disability evaluation include the following: information about on-going treatment records, including VA or other Federal treatment records, you have not previously told us about; recent Social Security determinations; statements from employers as to job performance, lost time, or other information regarding how your condition affects your ability to work; and statements discussing your disability symptoms from people who have witnessed how they affect you. Thus, the February 2008 VCAA letter addressed the fourth prong of the holding in Vazquez- Flores. Because there is no indication that there exists any evidence which could be obtained which would have an effect on the outcome of this case, no further VCAA notice is necessary. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) [VCAA notice not required where there is no reasonable possibility that additional development will aid the veteran]. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant's claim, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law provides that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. An examination is deemed "necessary" if the evidence of record (lay or medical) includes competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and indicates that the disability or symptoms may be associated with the claimant's active military, naval, or air service; but does not contain sufficient medical evidence for VA to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2007). The Board finds that reasonable efforts have been made to assist the veteran in obtaining evidence necessary to substantiate his claims, and that there is no reasonable possibility that further assistance would aid in substantiating them. The evidence of record includes the veteran's service medical records, VA and private treatment records, records from SSA, and reports of VA examinations in May and June 2007 with an addendum, which will be described below. The Board finds that all relevant evidence necessary for an equitable resolution of these issues has been identified and obtained. In short, the Board has carefully considered the provisions of the VCAA in light of the record on appeal, and for the reasons expressed above finds that the development of these issues has been consistent with the provisions of the VCAA. The veteran has been accorded ample opportunity to present evidence and argument in support of his claims. See 38 C.F.R. § 3.103 (2007). He failed to appear for the videoconference hearing before a Veterans Law Judge. Accordingly, the Board will proceed to a decision on the merits. (CONTINUED ON NEXT PAGE) 1. Entitlement to service connection for a thyroid disorder, Graves' disease, to include as secondary to service-connected PTSD. Pertinent law and regulations Service connection - in general In general, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. § 1110 (West 2002). For certain chronic disorders, including endocrinopathies, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2007). See also Santiago v. Brown, 5 Vet. App. 288, 292 (1993) [Graves' disease is considered to be a "chronic disease" under the law and therefore service connection may be granted on a presumptive basis to a veteran who suffers from it]. Notwithstanding the above, service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(a) (2007). In order to establish service connection for a claimed disorder, there must be (1) medical 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) medical 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). Service connection - herbicide exposure The law and applicable regulatory provisions pertaining to Agent Orange exposure, expanded to include all herbicides used in Vietnam, provide that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii) (2007). The law and regulations further stipulate the diseases for which service connection may be presumed due to an association with exposure to herbicide agents. 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. § 3.309(e) (2007). The following diseases are deemed associated with herbicide exposure, under VA law: chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma and diabetes mellitus (Type 2). See 38 C.F.R. § 3.309(e) (2007); see also 38 U.S.C.A. § 1116(f), as added by § 201(c) of the "Veterans Education and Benefits Expansion Act of 2001," Pub. L. No. 107-103, 115 Stat. 976 (2001) [which added diabetes mellitus (Type 2) to the list of presumptive diseases as due to herbicide exposure]. The foregoing diseases shall be service connected if a veteran was exposed to a herbicide agent during active military, naval, or air service, if the requirements of 38 U.S.C.A. § 1116, 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. The presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition other than those for which the Secretary of VA has specifically determined that a presumption of service connection is warranted. See 38 U.S.C.A. § 1116. Notwithstanding the foregoing law and regulations pertaining to presumptive service connection, a veteran-claimant is not precluded from establishing service connection for diseases not subject to presumptive service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Continuity of symptomatology In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2007). Secondary service connection Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a) (2007); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Analysis The veteran's seeks service connection for Graves' disease, both as being directly due to his military service, including presumed exposure to herbicides in Vietnam, and as secondary to his service-connected PTSD. "Graves' disease, also called hyperthyroidism, exophthalmic goiter, and toxic goiter, is described as 'excessive functional activity of the thyroid gland . . . , the resulting condition marked esp[ecially] by increased metabolic rate, enlargement of the thyroid gland, rapid heart rate, and high blood pressure.' Webster's [Medical Desk Dictionary (1986)] at 274, 315." Santiago v. Brown, 5 Vet. App. 288, 290 (1993) With respect to Hickson and Wallin element (1), current disability, the competent medical evidence demonstrates that the veteran currently has Graves' disease. Although the report of a June 1991 VA examination showed that the veteran had hypothyroidism and a November 2001 VA hospitalization record reveals a diagnosis of a past history of hypothyroidism, the reports of the June 1991, December 1995, and June 2007 VA examinations reflect that the veteran's thyroid disorder was initially hyperthyroidism, more specifically Graves' disease. The report of the June 2007 VA examination shows that the current diagnosis is still Graves' disease. Moreover, the report of the June 2007 shows that the veteran started taking levothyroxine in 1989 following his radiation therapy in 1989 for an overactive thyroid and that he still takes that medication. Therefore, Hickson and Wallin element (1), current disability, is met. As is noted elsewhere in this decision, service connection is in effect for PTSD. Accordingly, Wallin element (2) has been satisfied. With respect to Hickson element (2), in-service disease or injury, the Board will separately address the matters of in- service disease and in-service injury. With respect to in-service disease, service medical records do not show a diagnosis of a thyroid disorder. On the December 1969 separation examination, the endocrine system was normal. A thyroid disorder was first indicated in May 1989. Therefore, according to the evidence of record, the veteran's thyroid disorder began approximately 19 years after the veteran left military service in April 1970, and long after the end of the one year presumptive period in 38 C.F.R. § 3.309(a). The veteran appears to contend that he had symptoms of Graves' disease in service, to include weight loss and "protruding eyes". With respect to claimed weight loss, the veteran's service medical records show that he gained 20 pounds between his August 1967 pre-induction examination and his December 1969 separation examination. The service medical records indicate that in May 1969 he had conjunctivitis in the left eye following exposure to insecticide and that in November 1969 he had a cyst on the left upper eyelid. However, service medical records do not reflect that his eyes were described as "protruding". To the extent that the veteran is attempting to diagnose himself as having had symptoms of Graves' disease in service, it is now well established that lay persons without medical training, such as the veteran, are not competent to comment on medical matters such as diagnosis, date of onset or cause of a disability. See Espiritu v. Derwinski, 2 Vet. App. 491, 494-5 (1992); see also 38 C.F.R. § 3.159 (a)(1) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. The statements offered by the veteran are not competent medical evidence and do not serve to establish the existence of Graves' disease in service. Hickson element (2) as to in-service disease is therefore not met. With respect to in-service incurrence of injury, because the veteran served in Vietnam, his exposure to Agent Orange is presumed. See 38 U.S.C.A. § 1116(f) (West 2002). Hickson element (2), in-service injury, is therefore been established based on a presumptive basis. The critical question, accordingly, is whether Hickson and Wallin element (3), medical nexus, is satisfied. The Board will first discuss the matter of presumptive service connection under 38 C.F.R. § 3.309(e) [herbicide exposure]. The Board will then address the veteran's claim under Combee, supra, and as secondary to the service-connected PTSD. The disorder for which service connection is sought must be specified at 38 C.F.R. § 3.309(e) in order to enjoy the presumption of service incurrence thereunder. The disorders granted presumptive service connection under 38 C.F.R. § 3.309(e) for Agent Orange exposure are specified with precision. In this case, the disabilities specified at 38 C.F.R. § 3.309(e) do not include the veteran's diagnosed Graves' disease. The June 2007 VA examiner noted that thyroid disease is not among the list of presumed disorders due to Agent Orange. Therefore, the nexus presumption found in 38 C.F.R. § 3.309(e) is not applicable as to this claim. When a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See Combee, 34 F.3d at 1043-1044. Thus, the Board must additionally consider whether the veteran is entitled to service connection for his Graves' disease under the regular criteria for service connection without regard for the Agent Orange presumptions. There is of record a competent nexus opinion, which is contained in the report of the June 2007 VA examination and the September 2007 addendum to that examination report. That medical evidence is not favorable to the veteran's claim. The June 2007 VA examiner opined that the veteran's thyroid condition is not due to Agent Orange exposure or to symptoms of malaise while he was in service. With respect to the secondary service connection claim, the veteran's contentions as to how PTSD could be connected to Graves' disease are obscure. In any event, in the September 2007 addendum to the June 2007 VA examination, the VA examiner noted that Graves' disease is an autoimmune disease, and opined that it is not likely related to PTSD. To the extent that the veteran himself is contending that his Graves' disease is related directly to his military service, to include in-service eye complaints or malaise or is secondary to the service-connected PTSD, it is now well established that laypersons, such as the veteran, without medical training are not competent to comment on medical matters such as etiology. See Espiritu, supra. The Board observes that the veteran has had ample opportunity to provide medical nexus evidence in his favor. He has not done so. See 38 U.S.C.A. § 5107(a) (West 2002) (it is a claimant's responsibility to support a claim for VA benefits). The Board further observes that in essence the veteran has contended that he has experienced various symptoms which he evidently attributes to Graves disease continually since service. The Board is of course aware of the provisions of 38 C.F.R. § 3.303(b), discussed above, relating to chronicity and continuity of symptomatology. However, supporting medical evidence is required. See Voerth v. West, 13 Vet. App. 117, 120-1 (1999) (there must be medical evidence on file demonstrating a relationship between the veteran's current disability and the claimed continuous symptomatology, unless such a relationship is one as to which a lay person's observation is competent). Such evidence is lacking in this case. As noted above, the medical records do not contain competent medical evidence demonstrating a relationship between the veteran's current thyroid disease and the alleged continuity of symptomatology. In short, element (3) cannot be met by continuity of symptomatology. In summary, in the absence of the third required Hickson and Wallin element, medical nexus, the Board concludes that a preponderance of the evidence is against the claim of entitlement to service connection for Graves' disease on both a direct and a secondary basis. The benefit sought on appeal is accordingly denied. 2. Entitlement to service connection for a "stomach condition", to include as secondary to service-connected PTSD. Relevant law and regulations The law and regulations pertaining to direct and secondary service connection have been set out above and will not be repeated. Analysis With respect to Hickson and Wallin element (1), current disability, as an initial mater the Board reads the veteran's claim as encompassing any gastrointestinal disability. See EF v. Derwinski, 1 Vet. App. 324, 326 (1991) [VA must liberally construe all documents filed by a claimant]. The competent medical evidence demonstrates that the veteran currently has status post right hemicolectomy due to perforated diverticular disease. Hickson element (1), current disability, is met. As is noted elsewhere in this decision, service connection is in effect for PTSD. Accordingly, Wallin element (2) has been satisfied. With respect to Hickson element (2), in-service disease or injury, the Board will separately address the matters of in- service disease and in-service injury. With respect to in-service disease, service medical records do not show a diagnosis of diverticular disease. On the December 1969 separation examination, the abdomen and viscera were normal. Diverticular disease was first identified in October 2001, over 31 years after the veteran left military service in April 1970. However, the service medical records show that in August 1968 he had symptoms diagnosed as viral enteritis. Hickson element (2) is arguably met as to in- service disease. With respect to in-service incurrence of injury, the veteran is claiming that his in-service injury is exposure to herbicides. Because the veteran served in Vietnam, his exposure to Agent Orange is presumed. See 38 U.S.C.A. § 1116(f) (West 2002). Hickson element (2), in-service injury, has therefore also been established on a presumptive basis. The critical question, accordingly, is whether Hickson and Wallin element (3), medical nexus, is satisfied. The Board will first discuss the matter of presumptive service connection under 38 C.F.R. § 3.309(e) [herbicide exposure]. The Board will then address the veteran's claim under Combee, supra, and as secondary to the service-connected PTSD. As noted above, the disorders granted presumptive service connection under 38 C.F.R. § 3.309(e) for Agent Orange exposure are specified with precision. The disabilities specified at 38 C.F.R. § 3.309(e) do not include the veteran's diagnosed perforated diverticular disease. The VA examiner specifically noted that diverticulitis is not among the list of presumed disorders due to Agent Orange. Therefore, the nexus presumption found in 38 C.F.R. § 3.309(e) is not applicable as to this claim. With respect to Combee, the June 2007 VA examiner opined that the veteran's status post right hemicolectomy due to perforated diverticular disease is not likely due to military service and is not related to Agent Orange exposure. In a September 2007 addendum to the June 2007 VA examination, the VA examiner noted that the right hemicolectomy was due to a perforated diverticulum caused by diverticulosis and that this condition was not likely related to or due to PTSD. The VA examiner added that this condition was most likely due to the veteran's dietary habits. To the extent that the veteran himself is contending that his diverticular disease is related directly to his service or secondary to the service-connected PTSD, the Board again notes that the veteran is not competent to comment on medical matters such as etiology. See Espiritu, supra; see also 38 C.F.R. § 3.159 (a)(1). The veteran has had ample opportunity to provide medical nexus evidence in his favor. He has not done so. See 38 U.S.C.A. § 5107(a). In summary, in the absence of the third required Hickson and Wallin element, medical nexus, the Board concludes that a preponderance of the evidence is against the claim of entitlement to service connection for status post right hemicolectomy due to perforated diverticular disease on both a direct and a secondary basis. The benefit sought on appeal is accordingly denied. 3. Entitlement to service connection for drug and alcohol abuse, claimed as secondary to service-connected PTSD. Initial matter The Board notes that a March 2003 VA treatment record and the report of the May 2007 VA examination reflect that the veteran reported abusing alcohol and illegal drugs during service. Service connection cannot be granted based on such in-service use. See 38 U.S.C.A. § 105 (West 2002); 38 C.F.R. §§ 3.1(n), 3.301 (2007). The veteran in fact does not seek service connection on a direct basis. Rather, he claims that his drug abuse is secondary to his service-connected PTSD. Accordingly, the Board's discussion will be focused on that theory of entitlement. Relevant law and regulations The law and regulations pertaining to secondary service connection in general have been set out above and will not be repeated. Secondary service connection - alcoholism and drug abuse In general, the law and regulations provide that compensation shall not be paid if disability was the result of the person's own willful misconduct, to include the abuse of alcohol or drugs. See 38 U.S.C.A. §§ 105, 1110 (West 2002); 38 C.F.R. §§ 3.1(n), 3.301 (2007); see also VAOPGPREC 2-97 (Jan. 16, 1997). However, the United States Court of Appeals for the Federal Circuit has held that there can be service connection for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a service-connected disability. See Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). The Federal Circuit further stated that compensation may be awarded only "where there is clear medical evidence establishing that alcohol or drug abuse is caused by a veteran's primary service-connected disability, and where the alcohol or drug abuse disability is not due to willful wrongdoing." See Allen, 237 F.3d at 1381. Analysis With respect to Wallin element (1), the report of the May 2007 VA examination shows a diagnosis of a polysubstance abuse disorder involving primarily cocaine, and there is also ample evidence that the polysubstance abuse disorder also includes marijuana and alcohol abuse. As is noted elsewhere in this decision, service connection is in effect for PTSD. Accordingly, Wallin element (2) has been satisfied. With respect to crucial Wallin element (3), medical nexus, there is of record only one competent nexus opinion, which is contained in the report of a May 2007 VA examination. That opinion is not favorable to the veteran's claim. The VA examiner opined, rather confusingly, "[i]t is as unlikely as not that the veteran's drug and alcohol abuse problem is secondary to his post-traumatic stress disorder." Although the VA examiner's opinion could have been far better articulated, the clear substance of the opinion is that the veteran's polysubstance abuse disorder is not caused by or aggravated by the service-connected PTSD. Specifically, the examiner stated "[i]t should be noted that in reviewing the medical records there is no indication in any of the records that the veteran's drug and alcohol problems are secondary to his post-traumatic stress disorder." To the extent that the veteran himself is contending that his drug and alcohol abuse is secondary to the service-connected PTSD, the Board again notes that the veteran is not competent to comment on medical matters such as etiology. See Espiritu, supra; see also 38 C.F.R. § 3.159 (a)(1). In summary, in the absence of the third required Wallin element, medical nexus, the Board concludes that a preponderance of the evidence is against the claim of entitlement to service connection for drug and alcohol abuse as secondary to PTSD. The benefit sought on appeal is accordingly denied. 4. Entitlement to TDIU. Pertinent law and regulations It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16 (2007). A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15 (2007). "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." See Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16(a) (2007). The Court noted the following standard announced by the United States Eighth Circuit Court of Appeals in Timmerman v. Weinberger, 510 F.2d 439, 442 (8th Cir. 1975): It is clear that the claimant need not be a total 'basket case' before the courts find that there is an inability to engage in substantial gainful activity. The question must be looked at in a practical manner, and mere theoretical ability to engage in substantial gainful employment is not a sufficient basis to deny benefits. The test is whether a particular job is realistically within the physical and mental capabilities of the claimant. Moore, 1 Vet. App. at 359. A claim for a total disability rating based upon individual unemployability "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of 'subjective' factors that the 'objective' rating does not consider." See Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In Hatlestad v. Derwinski, 1 Vet. App. 164 (1991), the Court referred to apparent conflicts in the regulations pertaining to individual unemployability benefits. Specifically, the Court indicated there was a need to discuss whether the standard delineated in the controlling regulations was an "objective" one based on the average industrial impairment or a "subjective" one based upon the veteran's actual industrial impairment. In a pertinent precedent decision, the VA General Counsel concluded that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. It was also determined that "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91 (Dec. 27, 1991). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2007). A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. See 38 C.F.R. § 4.16(a) (2007). Rating boards shall submit to the Director of VA Compensation and Pension Service for extra-schedular consideration all cases of veterans who are unemployable by reason of service- connected disabilities but who fail to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a). The rating board will include a full statement as to the 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) (2007). Global Assessment of Functioning Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 (2007) [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130. Analysis The veteran is seeking entitlement to TDIU. Essentially, he contends that his service-connected disabilities have rendered him unemployable. For the reasons set out immediately below, the Board has determined that the veteran has not met the criteria for TDIU on either a schedular or an extraschedular basis. Schedular basis The veteran's service-connected disabilities are the following: PTSD, evaluated as 50 percent disabling; and scar as a residual of a removal of a cyst from the left upper eyelid, evaluated as zero percent disabling. A combined disability rating of 50 percent is in effect. Therefore, the veteran fails to meet the schedular criteria for consideration of a total rating based on individual unemployability due to having either one disability rated 60 percent disabling or having more than one service-connected disabilities with a combined 70 percent disability rating. See 38 C.F.R. § 4.16(a) (2007). Extraschedular basis For a veteran to prevail on a claim for TDIU on an extraschedular basis, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). In this case, the evidence of record does not show that the veteran's service-connected disabilities are so exceptional or unusual that they alone are sufficient to cause the veteran to be unemployable. The veteran is 60 years old. He is currently unemployed. His career has been in manual labor, with his last job being a groundskeeper. According to his TDIU claim, he last worked in 1988. He completed three years of high school. The Board notes that there is no competent medical evidence that the veteran is in any way unemployable or limited in employability because of the service-connected scar on his left upper eyelid, and that the veteran has not asserted otherwise. Thus, the Board's inquiry will be directed towards the impact that the service-connected PTSD has on his employability. It is undisputed that the veteran has been diagnosed has having PTSD, which has been service connected. However, as was alluded to above, the veteran has a significant polysubstance abuse disorder. The Board has denied service connection therefor. Compensation can only be granted for service-connected disabilities. See 38 U.S.C.A. § 101(13) (West 2002). Thus, in considering the veteran's TDIU claim, it is incumbent upon the Board to identify, and disregard, any limitations on employability which are due to the non service-connected polysubstance abuse disorder. However, the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The reports of VA examinations and VA treatment records reflect that the veteran has significant psychiatric problems which appear to have led to being unemployable. However, those reports indicate that the vast majority of his psychiatric symptomatology is attributable to his non service-connected polysubstance abuse disorder rather than to his service-connected PTSD. A June 2004 VA treatment record shows that a current GAF score of 50 and a GAF score of 55 for the highest level of functioning in the past year were assigned for the following disorders: other and unspecified alcohol dependency; unspecified drinking behavior; cocaine dependency, continuous use; cocaine-induced mood disorder; and polysubstance dependency. The VA treating therapist did not diagnose PTSD. Therefore, these GAF scores are solely based on the veteran's polysubstance abuse disorder and related disorders. Similarly, a July 2006 VA treatment record reflects that the veteran reported alcohol and cocaine use as recent as two days earlier. The VA therapist assigned a GAF score of 55 for the following disorders listed in this order: polysubstance dependence; cocaine dependence, continuous use; other and unspecified alcohol dependency, unspecified drinking behavior; other (or unknown) substance-induced mood disorder; and PTSD, chronic, severe. The report of the May 2007 VA examination shows that the examiner assigned a GAF of 50 for the chronic PTSD and continuous polysubstance abuse disorder, primarily cocaine. The examiner stated "[w]hile the veteran is clearly not incompetent, he would be benefit from oversight and supervision of his funds due to his continuous drug use." [Emphasis added by the Board.] This comment reflects that the veteran's primary psychiatric disorder is his polysubstance abuse disorder. The Board wishes to make it clear that the veteran's service- connected PTSD undoubtedly interferes with his industrial capacity. However, any such interference is reflected in the 50 percent disability rating that is currently assigned. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1 (2007). Indeed, 38 C.F.R. § 4.1 specifically states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. For his part, the veteran contends that he cannot work due to his PTSD. In evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility, and therefore the probative value, of proffered evidence in the context of the record as a whole. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In this case, the totality of the evidence, including VA treatment records and the report of the May 2007 VA examination, clearly demonstrates that the veteran is not precluded from working due to his service-connected PTSD. Indeed, the record does not contain any medical opinion which indicates that the veteran is precluded from working due to PTSD. Thus, although the Board has taken the veteran's statements into consideration, it attaches relatively little weight of probative value to the veteran's own self-assessment. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) [VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence]. Further, there is no evidence in the medical records of an exceptional or unusual clinical picture, of frequent hospitalizations due to the service-connected PTSD, or of any other reason why TDIU should be considered on an extraschedular basis. The veteran has pointed to no such medical evidence. In fact, it appears that the veteran's psychiatric treatment is for his polysubstance abuse disorder and not his PTSD. In short, the question before the Board is whether the veteran's service-connected disabilities make it impossible for the veteran to follow a substantially gainful occupation. Based on the evidence of record, the service-connected disabilities, although limiting to some extent, allow the veteran to perform tasks that would be required in employment. The Board accordingly finds that employment is "realistically within the physical and mental capabilities" of the veteran. See Moore, 1 Vet. App. at 359. Therefore, the Board concludes that the veteran's service-connected disabilities do not affect his ability to secure and follow a substantially gainful occupation. For the reasons stated, the Board has concluded that the veteran's claim for TDIU does not warrant referral to the Director of the VA Compensation and Pension Service for extra-schedular consideration. The veteran's claim of entitlement to TDIU is accordingly denied. ORDER Service connection for a thyroid disorder, Graves' disease, claimed on a direct basis and as secondary to PTSD, is denied. Service connection for a "stomach condition", diagnosed as status post right hemicolectomy due to perforated diverticular disease, claimed on a direct basis and as secondary to PTSD, is denied. Service connection for drug and alcohol abuse, claimed as secondary to PTSD, is denied. Entitlement to TDIU is denied. ___________________________________________ Barry F. Bohan Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs