Citation Nr: 0811554 Decision Date: 04/08/08 Archive Date: 04/23/08 DOCKET NO. 06-08 663 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an increased disability rating for anxiety disorder, currently rated as 50 percent disabling. 2. Entitlement to an increased disability rating for duodenal ulcer, currently rated as noncompensably (0 percent) disabling. 3. Entitlement to total disability rating based upon individual unemployability (TDIU). ATTORNEY FOR THE BOARD D. Johnson, Associate Counsel INTRODUCTION The veteran served on active duty from August 1966 to July 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2005 decision rendered by the Philadelphia, Pennsylvania Regional Office (RO) of the Department of Veterans Affairs (VA), which denied claims for increased ratings for service-connected anxiety disorder and duodenal ulcer. By this rating action, the RO also denied a claim of total disability rating based upon individual unemployability. FINDINGS OF FACT 1. The evidence demonstrates the veteran's service-connected anxiety disorder is of moderate severity and is primarily manifested by moderate symptoms of impaired sleep, concentration, and impulse control, with unprovoked irritability; depression; and difficulty in adapting to stressful circumstances, such as in a work-like setting 2. A duodenal ulcer is productive of no more than moderate symptoms primarily controlled by medication. 3. The veteran's service-connected disabilities of anxiety disorder, rated 50 percent disabling and duodenal ulcer, rated 20 percent disabling have not been shown to alone preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for an anxiety disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2006); 38 C.F.R. § 4.130, Diagnostic Code 9400 (2007). 2. The criteria for an increased rating to 20 percent, and no higher, for a duodenal ulcer have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2006); 38 C.F.R. § 4.114, Diagnostic Code 7305 (2007). 3. The veteran's service-connected disabilities do not render him individually unemployable. 38 U.S.C.A. § 1155 (West 2002 & Supp.2005); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2005); 38 C.F.R. § 3.159(b) (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record that is necessary to substantiate the claim. It should inform the claimant of what information and evidence VA will seek to provide, and what information and evidence the claimant is expected to provide. Proper notice should also invite the claimant to provide any evidence in his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The Board notes that a substantially complete claim was received in February 2005. Since then, the provisions of the VCAA have been fulfilled by information provided to the veteran in a letter from the RO/AMC dated in March 2005, with additional notices in June 2005, July 2005, and August 2005. These letters notified the veteran of VA's responsibilities in obtaining information to assist the veteran in completing his claim, identified the veteran's duties in obtaining information and evidence to substantiate his claim, and requested that the veteran send in evidence in his possession that would support his claim. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). During the pendency of this appeal, on March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a claim, including the degree of disability and the effective date of an award. Ideally, the veteran should have been provided such notice prior to the initial decision on his claim. For the matter granted in part below, the veteran will be afforded notice regarding effective dates and ratings by the RO. If there has been any deficiency in the notice to the veteran, the Board finds that the presumption of prejudice on the VA's part has been rebutted in this case based on the written notices provided to the veteran by the VA over the course of this appeal. VA has also made reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefits sought. 38 U.S.C.A. § 5103A (West 2002). The information and evidence associated with the claims file includes service medical records, VA and private medical treatment records, Social Security (SSA) disability records and reports from VA examinations. The veteran has not identified any outstanding pertinent evidence for VA to obtain, and the Board is likewise unaware of such. For an increased-compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the Diagnostic Code under which the claimant is rated 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 that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be 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 noncompensable to as much as 100 percent (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. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary 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. Vazquez-Flores, supra. In this case, the Board is aware that none of the VCAA letters cited above contained the level of specificity set forth in Vazquez-Flores. Id. Nonetheless, the Board does not find that any such procedural defect constitutes prejudicial error in this case because of the evidence of actual knowledge on the part of the veteran, and other documentation in the claims file that reflects notification such that a reasonable person could be expected to understand what was needed to substantiate the claim(s). See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). In the veteran's February 2005 formal claim, he stated that he could not work due to his anxiety and anger at people around him. He also indicated that he isolated himself from others so as to avoid arguments and fights and was "easily wound up." The veteran later submitted a highlighted copy of a Social Security Administrative decision, which awarded disability benefits due to his anxiety and gastrointestinal disorders, as further evidence to support his claims. Such actions demonstrate the veteran's awareness of the need to show evidence of the effect that his worsened disability has on his employment and daily life, and thus satisfies the first and fourth requirements of Vazquez-Flores. The March 2005 VCAA letter also specifically noted that the veteran could submit statements from persons who could describe from personal knowledge and observation how his disability symptoms had worsened. He was also informed that he could submit his own personal statement describing his symptoms, their frequency, severity, other involvement and any additional disability caused by his service-connected disabilities. The letter also suggested various types of medical evidence that could support the veteran's claim. Additionally, and particularly in light of the veteran's lay assertions of effects of the service-connected disabilities on employability and daily life, (including comments made during his VA examinations) the Board does not view the anxiety and gastrointestinal disorders at issue to be covered by the second requirement of Vazquez-Flores, and no further analysis in that regard is necessary. Furthermore, the October 2005 rating decision includes a discussion of the rating criteria utilized in the present case, and this criteria was set forth in further detail in the February 2006 Statement of the Case (SOC) and the October 2006 Supplemental Statement of the Case (SSOC). The veteran was accordingly made well aware of the requirements for an increased evaluation pursuant to the applicable diagnostic criteria, and such action thus satisfies the third notification requirement of Vazquez-Flores. Id. Finally, the Board notes that in Vazquez, the Court did not address the applicability of the heightened notice standard to a claim for TDIU. Therefore, in the absence of further guidance in that regard, the Board's prejudicial analysis is narrowly construed to apply only to the increased rating claims at issue. For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify (each of the four content requirements) and the duty to assist pursuant to the VCAA. See 38 U.S.C.A. §§ 5102 and 5103 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159(b), 20.1102 (2007); Pelegrini, supra; Quartuccio, supra; Dingess, supra; Vasquez, supra. Analysis Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The veteran is presumed to be seeking the maximum benefit allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, (1993). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Anxiety Disorder In February 2005, the RO received the veteran's claim for an increased rating for his service-connected generalized anxiety disorder. The veteran essentially contends that his disorder has increased in severity and now warrants a disability evaluation in excess of 50 percent. What follows are pertinent portions of the criteria for evaluating mental disorders, along with the corresponding rating. Total occupational and social impairment, due to such symptoms as: Gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name 10 0 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: 70 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 worklike setting); inability to establish and maintain effective relationships Occupational and social impairment with reduced reliability and productivity due to such symptoms as: 50 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 38 C.F.R. § 4.130, Diagnostic Code 9400 (2007). In assessing the evidence of record, it is important to note that the GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). The Board has reviewed the medical evidence since February 2004, which includes records of VA and private medical treatment and VA examinations. In this case, the Board finds that the veteran's psychiatric symptoms have been at most moderately disabling and do not warrant a rating in excess of 50 percent under 38 C.F.R. § 4.130, Diagnostic Code 9400. Private treatment records dated between February 2004 and May 2005 reveal the veteran generally maintained a level mood. His thoughts were coherent, and did not involve suicide. A December 2004 record shows the veteran was more anxious, nervous, and depressed. Additionally, he had been crying at night. It was noted, however, that at the time of that record, he had been off of his medications for two weeks. VA outpatient treatment records (including those associated with the veteran's Social Security disability file) reflect that between February 2004 and April 2004 the veteran was sleeping poorly, feeling more anxious and restless, frustrated and irritable. He also endorsed passive suicidal thoughts. Additional VA outpatient treatment records dated between October 2004 and February 2005 reflect that upon evaluation the veteran had a fair memory, and fair judgment and insight into his situation for the most part. The veteran consistently denied homicidal ideations, although on at least two occasions he endorsed passive thoughts of suicide without any plan or intent. There were no reported auditory or visual hallucinations. His mood ranged from depressed, dysphoric to neutral. The veteran's speech was consistently noted to be regular. A treatment record dated in October 2004 reflects that the veteran had poor impulse control, and was snapping at others for minor things, and tending to isolate himself. Another VA clinical note, dated in November 2004, shows that the veteran's strengths included the ability to establish and maintain relationships. The veteran was found to adequately perform his activities of daily living skills, and he was reportedly friendly. It was also noted that his weakness was that he was easily agitated. A record dated in January 2005 shows that after receiving medication from his private physician, the veteran was sleeping better and feeling less anxious and depressed. Treatment records dated in March 2005 show the veteran reported sleep disturbances. It was also noted that he and his sister operated as caretakers for their ailing elderly father. The veteran underwent a VA examination in April 2005. He was noted to be on several psychotropic medication trials. A prior history of several suicide attempts was noted. The veteran seemed stable, with only passive suicidal thoughts without plans or intent. The veteran reported continuing problems with distress, depression, and anxiety. He reported that his father had recently passed away and noted he was struggling with that. He remained unemployed. The veteran reported minor symptoms of lethargy and anhedonia, but denied any suicidal thoughts. Upon physical examination, the veteran was casually dressed and groomed. He appeared to be anxious throughout the evaluation, but there was no physical agitation. Panic attacks appeared to be short lived in the context of fear and anxiety. The veteran was alert and oriented, but concentration was impaired. His thought processes were clear and free of obsessions, and was coherent, goal-directed, and logical. His speech was pressured at times, but otherwise within normal limits. The veteran denied any current plan to harm himself. He was noted to have chronic passive suicidal thoughts episodically. There were no thoughts of suicide during the examination. Judgment and insight were felt to be pretty good and there was no evidence of any major memory disturbances. The veteran was noted to have agoraphobic symptoms, and some peripheral symptoms of PTSD. The examiner noted that the current depressive symptoms appeared to be bereavement-related and not related to major depression. The AXIS I diagnosis impression was history of generalized anxiety disorder and depression recurrent. The GAF score was 50-55. The veteran underwent another VA examination in May 2006. His claims file was reviewed in its entirety. The veteran's subjective complaints included feeling depressed, nervous, and anxious, with panic attacks. He noted changes in his eating and appetite, low energy, an inability to stay focused or listen well. The veteran also endorsed symptoms of intermittent irritability and difficulty relaxing. The examiner noted that the veteran's chief complaint seemed to be that he was not receiving more funding from VA. The examiner further noted that there seemed to be no real interval change in the veteran's past psychiatric history. Upon further questioning, the veteran indicated that he was no longer employed because he could not walk and that he was receiving Social Security disability income because of his anxiety. He explained that he became flustered, upset, angry, depressed, sad and dysphoric when he tried to work. As such, he does not attempt to do so. The veteran stated that he primarily sat around and watched television. The veteran also indicated that he was currently romantically involved with the woman he was living with and wished to marry her. With regard to functioning, the veteran initially indicated that he only watched television, cut the grass and tried to keep busy in the house. After further questioning by the examiner though, the veteran indicated that he did eat out socially with his lady-friend, ran errands, and attended the movies on occasion. He also kept in touch with his sister and brother, but not with close friends (as those in the area have all died, gotten married, or drank). Upon objective evaluation, the veteran was causally dressed and groomed and appeared to be in no acute distress. Eye contact was good, speech was pressured. The veteran was somewhat circumstantial in his thinking. He did not appear to have a psychotic nature, but rather an anxious one. Thought process was clear, coherent, and mostly goal- directed. The veteran denied any auditory or visual hallucinations. There was no clear evidence of paranoia and there were no obsessions. In terms of sensorium, the veteran was alert and oriented. There was no evidence of any major concentration or memory disturbances. Judgment and insight were fair. Affect was not restricted. The examiner commented that there appeared to be a reliability issue in that the veteran seemed very motivated to receive more compensation, and it was difficult to discern the accuracy of the information provided. In this regard, the veteran was determined to be at least partially reliable. The AXIS I diagnosis was major depression, generalized anxiety disorder with some post-traumatic stress disorder symptoms. The GAF appeared to be in the 50-60 range. Based on a review of the record, the veteran's anxiety disorder primarily manifests with symptoms of sleep impairment, impaired concentration, and impaired impulse control with unprovoked irritability, depression, and difficulty in adapting to stressful circumstances, such as in a work-like setting. These cumulative objective findings are consistent with the assignment of a 50 percent evaluation under the rating criteria discussed above. The objective clinical evidence of record does not more closely approximates the criteria required for a 70 percent evaluation or higher. While there is some evidence that the veteran has endorsed passive suicidal thoughts on several occasions and has demonstrated impaired impulse control (such as periods of unprovoked irritability), the Board notes that he has not indicated any specific intent or plans to follow through of such thoughts and there is no indication of any physically violent behavior. It has been consistently reported that the veteran does not have hallucinations or delusions, or homicidal thoughts. Moreover, there is no evidence of: obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; or neglect of personal appearance and hygiene. Rather, the clinical evidence reveals the veteran has consistently maintained normal, although at times, pressured speech. His thoughts have been coherent and he has been alert and oriented. In addition, the Board notes that the veteran was capable of serving as a caretaker for his ailing father up until his father's death in 2005. Moreover, the record demonstrates that the veteran is able to establish and maintain effective relationships. He communicates regularly with two of his siblings and is currently involved in a romantic relationship with an individual that he wishes to marry. The veteran also enjoys recreational activities outside his home, such as eating out and seeing movies. Finally, the veteran's GAF scores have been reportedly in the 50 to 60 range. A score of 51-60 is assigned where there are "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)." See DSM-IV at 32). Accordingly, the Board concludes that the veteran's generalized anxiety disorder does not meet nor more nearly approximate the level of disability required for a rating in excess of 50 percent. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a higher rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Ulcer The veteran contends his service-connected duodenal ulcer has increased in severity and warrants a compensable rating. The veteran's duodenal ulcer has been rated as noncompensably (0 percent) disabling since March 1998. He filed the current claim for an increased rating in February 2005. Under 38 C.F.R. § 4.114, Code 7305 (for rating duodenal ulcer), a compensable rating of 10 percent requires mild degree of impairment; with recurring symptoms once or twice yearly. To warrant a 20 percent disability rating, there must be medical evidence of recurring episodes of severe symptoms two or three times a year averaging ten days in duration; or recurring episodes with moderate manifestations. To warrant a 40 percent disability evaluation, the evidence must demonstrate moderately severe symptoms of impairment manifested by weight loss and anemia; or recurrent incapacitating episodes averaging ten days or more in duration at least four or more times per year. For a 60 percent evaluation to be assigned, the evidence must show severe ulcer, only partially relieved by standard therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114, Code 7305 (2007). There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. 38 C.F.R. § 4.113. Recent private and VA treatment records dated from February 2004 to May 2005 show that the veteran was treated for multiple disorders including ulcer problems. Private medical records show the veteran lost a total of seven pounds over the course of 2004; however he consistently denied abdominal tenderness or masses or belly pain during clinical evaluations. VA outpatient treatment records (including those associated with the Social Security disability file) reflect the veteran's abdomen was consistently soft, nontender and nondistended, without organomegaly or masses upon clinical evaluation. Treatment records in April 2004 reveal that the veteran reported having mild discomfort with epigastric palpation. He was also noted to have lost ten pounds since March. The clinical assessment was nausea and dysphagia. An upper gastrointestinal study in June 2004 showed the veteran had a moderate hiatal hernia with low level gastroesophageal reflux disease, and severe esophageal dysmotility. The esophageal motility was noted to be very poor and there was one episode of aspiration during the study. Significantly, the mucosa of the stomach and duodenal bulb was unremarkable. There was no filling defect or ulcerative lesion. There also was no gastric outlet obstruction. A December 2004 clinical note shows the veteran reported having burning with bowel movements, but he otherwise denied any occurrences of black or bloody stools. A March 2005 clinical record shows the veteran reported two episodes of having vomited undigested food after dinner and breakfast. He indicated vomiting had occurred approximately 10 times, over the course of two days. He also reported significant pain upon swallowing on the second day, but by the third day the symptoms improved. The veteran underwent a VA examination in May 2006. The examiner's review of the record revealed the veteran had been diagnosed with a duodenal ulcer while separating from military service. He was treated with hospitalization and medicines for approximately one month prior to being officially discharged. He did not have bowel or gastric surgery. Since discharge from service, the veteran had been treated on two occasions for gastritis, which was probably non-steroidal analgesic induced. Upon questioning, the veteran reported a daily sensation of food backing up from his stomach, into his mouth, and sticking at the base of his esophagus. He also had intermittent burning and sour taste. He denied vomiting, hematemesis, but thought he had melena about once a month. The veteran also reported that his stools were variable in character and had been so for a number of years. He currently used Metamucil and laxatives to control his bowels; but was not taking any medication for his gastrointestinal tract other than over-the-counter TUMS for short-term relief. He was awaiting approval for Aciphex, which in the past was successful in controlling his symptoms. Several other medications have been unsuccessful. The veteran also complained of some episodes of colic and abdominal bloating, which was attributed to food intake. He further noted that his weight has ranged from 170-180 over the past few years. Upon physical examination, the veteran's abdomen was soft, nontender, nondistended, with positive bowel sounds. There was no evidence of hepatosplenomegaly, guarding, bruits, or rebound. Stool cards dated in April 2006 were negative. The final assessment was that the veteran still had some residual symptomatology, controlled on medications to some degree. Based upon a review of the evidentiary record and in light of the VA examiner's clinical findings, the Board finds that the veteran's symptoms more nearly approximate the criteria for an initial rating of 20 percent under Diagnostic Code 7305 for moderate symptoms attributed to his duodenal ulcer. The evidence demonstrates the ulcer manifests with daily (continuously recurring) symptoms that include the daily sensation of food sticking in the base of his throat, general epigastric discomfort and burning, and sour taste. The medical examiner opined that the veteran's symptoms are not completely relieved even when he is taking medication. Thus, a 20 percent evaluation is warranted. The Board has considered whether an even higher rating is warranted. A higher rating of 40 percent or higher is not warranted as the evidence fails to establish the presence of any moderately severe or severe symptoms (e.g. periodic vomiting, recurrent hematemesis or melena; or anemia or weight loss productive of definite impairment of health). The veteran has only had two episodes of vomiting, which occurred over a continuous two-day period. He has also consistently denied abdominal pain upon clinical evaluation. An increased schedular rating above 20 percent is not warranted. The Board finds no exceptional circumstances in the present case which would warrant referral for consideration of an extraschedular evaluation. The Board has been unable to identify an exceptional or unusual disability picture, and nothing of that nature has been identified or documented by the veteran or his representative. The record does not reflect that the veteran has been hospitalized for the treatment of his ulcer disorder. Nor is there sufficient evidence of record reflecting that this disorder alone has caused marked interference with employment. TDIU Under the applicable criteria, a TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected disabilities, provided that one of those disabilities is ratable 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16. The veteran has compensable service-connected disabilities as follows: duodenal ulcer (rated as 20 percent disabling) and generalized anxiety disorder (rated as 50 percent disabling). His combined disability evaluation is 60 percent, and accordingly does not meet the threshold criteria for a TDIU. Therefore, the material issue is whether he is unable to secure substantially gainful employment consistent with his education and occupational experience due to his service- connected disabilities, alone. 38 C.F.R. §§ 3.321, 4.16; see Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For a veteran to prevail on a total rating claim, the record must reflect some factor that takes the claimant's case outside the norm. The sole fact that a veteran is unemployed or has difficulty finding employment is not enough, since a high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment; the question is whether the claimant is capable of performing the physical and mental acts required for employment, not whether the claimant can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Consideration may be given to the veteran's education, training, and special work experience, but not to his age or to impairment cause by nonservice- connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 1.419; see also Van Hoose, id at 363. The veteran asserts that he cannot work due to his service- connected generalized anxiety disorder. On the veteran's VA Form 21-8940, Application for Compensation Based on Unemployability, he indicated that he had last worked April 2001, and had not tried to obtain employment since. He indicated working in various full-time positions prior to that time. A VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, completed in June 2005, shows that the veteran also worked a total of 18 days in January 2002, before resigning. Social Security disability (SSA) records reflect that in December 2004, the veteran was awarded disability benefits for anxiety related disorders, including depression and post- traumatic stress disorder (PTSD). The date of onset of his disability was determined to be December 15, 2002. The veteran essentially argues that the SSA award is sufficient proof that he is entitled to TDIU benefits. The Board notes however, that while SSA records may be "pertinent" to VA claims, the VA is not bound by the findings of disability and/or unemployability made by SSA and other agencies, including. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992); Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). The SSA records in question reflect that the primary diagnosis for the determination of benefits was PTSD. The secondary diagnosis was hiatal hernia. Further review of the SSA administrative law judge's (ALJ) decision reveals that an impartial psychology expert indicated that the veteran's PTSD was severe enough to preclude substantially gainful employment. Another significant factor in the ALJ's decision was evidence in the record that the veteran had been hospitalized in 2003 for an attempted overdose. Notably, the Board's review of the pertinent hospital admission and discharge records reveal that a diagnosis of PTSD was made in conjunction with this hospitalization and treatment. The veteran is not service-connected for PTSD, and prior applications to VA for service connection for PTSD have been denied. Therefore, as the award of SSA benefits demonstrates a non-service-connected disability which significantly affects the veteran' ability to obtain and maintain employment - TDIU benefits are not appropriate. There otherwise is no competent medical evidence of record to the effect that the veteran is unable to obtain and/or maintain substantially gainful employment due to his service- connected disabilities of duodenal ulcer and generalized anxiety alone. The veteran is adequately compensated for his service-connected disabilities by the current combined evaluation of 60 percent. See Van Hoose, supra. Based on the foregoing, the Board finds that the preponderance of the evidence is against his claim of entitlement to a TDIU. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application in reaching the decision in the instant case. See generally Gilbert v. Derwinski, 1 Vet. App. at 55-57 (1990); see also Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Consequently, this claim must be denied. ORDER An increased disability rating for anxiety disorder, currently rated as 50 percent disabling, is denied. A compensable disability evaluation of 20 percent for duodenal ulcer is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a total disability rating based upon individual unemployability is denied. ____________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs