Citation Nr: 0812469 Decision Date: 04/15/08 Archive Date: 05/01/08 DOCKET NO. 06-00 897 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection, to include on a secondary basis, for hypertension. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to an increased disability rating for post- traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. 4. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Thomas H. O'Shay, Counsel INTRODUCTION The veteran had active military service from November 1965 to November 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal of December 2004 and February 2005 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Service connection for diabetes mellitus was severed in a June 2005 rating decision. In occasional statements concerning his medical history offered to his health care providers, the veteran reports that he has diabetes mellitus. If he wishes to file an application to reopen the claim of service connection for diabetes mellitus, he should so inform the RO. FINDINGS OF FACT 1. Hypertension did not originate in service or within one year of the veteran's discharge therefrom, is not otherwise etiologically related to service, and was not caused or chronically worsened by service-connected disability. 2. Sleep apnea did not originate in service, is not otherwise etiologically related to service, and was not caused or chronically worsened by service-connected disability. 3. The veteran's PTSD is manifested by symptoms including sleep impairment, anxiety, irritability and anger, moderate impairment of impulse control, depressed mood, mild memory impairment, and some difficulty in establishing and maintaining effective work and social relationships, but not by symptoms such as impairment in thought processes or communication, inappropriate behavior, difficulty in performing activities of daily living, disorientation, speech which is illogical, obscure or irrelevant, near continuous panic or depression, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, or other symptoms productive of total occupational and social impairment, or occupational and social impairment in most areas. 4. The veteran's service-connected disabilities are not shown to preclude him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by active service, and is not proximately related to service-connected disability, nor may service connection be presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2007). 2. Sleep apnea was not incurred in or aggravated by active service, and is not proximately related to service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.310(a) (2007). 3. The criteria for a 50 percent evaluation for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2007). 4. The criteria for a TDIU due to service-connected disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's duties to notify and assist Under 38 U.S.C.A. § 5103, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate the claim, and of which information and evidence that VA will seek to provide and which information and evidence the claimant is expected to provide. Furthermore, in compliance with 38 C.F.R. § 3.159(b), the notification should include the request that the claimant provide any evidence in his possession that pertains to the claim. In the present case, VA provided the veteran with the contemplated notice in a July 2004 correspondence, except for notice concerning the initial disability rating and effective date to be assigned in the event service connection is granted for his claimed disorders, or the effective date to be assigned in the event an increased rating for PTSD or a TDIU was awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that, as to the service connection issues, the July 2004 notice letter advised him of the information and evidence necessary to substantiate his claims on both primary and secondary bases. Although the letter did not specify that it also applied to the claim for service connection for sleep apnea on a secondary basis, the Board points out that it did provide him with the relevant criteria for establishing service connection on both bases. The Board finds that a reasonable person would understand from the letter what information and evidence was needed to substantiate either claim on a primary or a secondary basis. See Sanders v. Nicholson, 487 F.3d 881, 887 (Fed. Cir. 2007). As to notice concerning initial disability ratings and effective dates, the veteran was provided with notice as to those matters in a March 2006 communication, following which his claim was readjudicated in a July 2007 supplemental statement of the case. The veteran therefore has received the notice to which he is entitled as to his claims, and there is no prejudice flowing from the timing of notice in this case. See Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007). The Board notes that the United States Court of Appeals for Veterans Claims (Court), in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) clarified VA's notice obligations in increased rating claims. The Court held that a notice letter must inform the veteran that, to substantiate a claim, he or she must provide, or ask VA 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. The Court also held that where the claimant 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 that worsening has on the claimant's employment and daily life, the notice letter must provide at least general notice of that requirement. The Board finds that the March 2006 correspondence essentially provided the type of notice required by Vasquez- Flores. The letter informed him that in assigning a disability rating, evidence of the impact of the condition and symptoms on employment is important. He was provided with examples of evidence that would assist in determining the proper disability rating to assign, including information regarding how his condition affected his ability to work, and statements from witnesses who have noticed how his symptoms had affected him. In effect, the correspondence advised him that relevant evidence included that tending to show all aspects of disablement. Even assuming, however, that the March 2006 notice letter did not completely advise the veteran as to the effect of the worsening on his employment and daily life, the Board finds that he has demonstrated actual notice of the need for evidence showing such an effect. In this regard, the record shows that in a December 2005 correspondence, the veteran provided specific examples of how his PTSD impacted on his social relationships, as well as his daily activities. In other statements made to VA examiners in connection with his appeal, he explained the impact of his disorder on his work history. In fact, on several examinations the examiners reported the veteran's detailed characterization of how his PTSD led to his current employment status. The Board finds that the veteran's statements to VA and to his examiners demonstrates that he has actual knowledge of the need for medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on his employment and daily life. The record shows that he has been provided with the specific criteria for evaluating PTSD. Consequently, the Board finds that any prejudice flowing from the failure of the July 2004 correspondence to provide such notice has been rebutted. See Sanders v. Nicholson, 487 F.3d 881, 891 (Fed. Cir. 2007). In short, the July 2004 and March 2006 notice letters collectively provided 38 U.S.C.A. § 5103(a)-compliant notice, and any timing deficiency has been cured by the issuance of the July 2007 supplemental statement of the case, obviating any need to address whether the veteran was prejudiced by a notice error in this case. Based on the procedural history of this case, the Board concludes that VA has complied with any duty to notify obligations set forth in 38 U.S.C.A. § 5103(a). With respect to VA's duty to assist the veteran, the Board notes that pertinent records from all relevant sources identified by him, and for which he authorized VA to request, were obtained by the RO or provided by the veteran himself. 38 U.S.C.A. § 5103A. In this regard, the Board notes that the veteran reports receiving disability benefits from the Social Security Administration (SSA), and also contends that he received treatment at the El Paso Vet Center between 2001 and 2003. The record shows that the RO attempted to obtain records from the SSA, but was notified in December 2006 that after an exhaustive search, no records in the possession of that agency for the veteran could be located. In February 2007 the RO advised the veteran of SSA's response, and requested that he provide any relevant documents in his possession. He did respond. As for the El Paso Vet Center, the file does contain records from that facility, but not for the period between 2001 and 2003. The RO attempted to obtain records for the referenced period, but was informed by the El Paso Vet Center that no such records were available. The RO advised the veteran of this response and of VA's efforts in July 2007 and August 2007 correspondences. The July 2007 letter invited him to submit any evidence from the facility in his possession, and the record shows he complied. In light of the above, the Board finds that further efforts to obtain records for the veteran from either the SSA or the El Paso Vet Center would be futile, and that VA's duty to assist him in obtaining such records has been met to the extent required. The record also shows that the veteran was afforded a VA examination as to his service connection claims in September 2004, along with numerous VA examinations with respect to the PTSD claim. The September 2004 examination included a January 2005 addendum addressing whether the veteran's hypertension and sleep apnea disorders were secondary to diabetes mellitus. At the time, this responded to the veteran's proffered theory of entitlement. The examination did not include an opinion as to whether those disorders were etiologically related to service, including to any exposure to herbicides. The Board finds, however, that a medical opinion addressing direct service connection is not necessary in this case. In this regard, the Board notes that a VA examination or opinion is necessary where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board notes that it was first following the examination that the veteran alleged that his hypertension resulted from exposure to herbicides in service. Although the veteran contends that he served in combat during service, and even assuming he did, the Board points out that he does not allege that he was treated, or even had, hypertension in service or until decades after service. See generally, 38 U.S.C.A. § 1154(b) (West 2002). Nor has he otherwise pointed to any symptoms in service or in the years since service he believes represented hypertension. As to the sleep apnea, he does not contend that he was treated for the disorder or any associated symptoms in service, or that any particular event in service caused sleep apnea. He contends instead that his former spouse, whom he met several months after service, noticed him snoring when she would spend the night. Turning first to hypertension, although there is evidence of an event in service (exposure to herbicides) and a current diagnosis, there is no indication that the hypertension is related to the event in service. In his statements, the veteran does not provide an observation of symptoms in service and continuing thereafter. Rather, he is asserting his own opinion that his current hypertension is related to herbicide exposure. Hypertension is not listed as a disease subject to presumptive service connection on an herbicide basis. See 38 C.F.R. § 3.309(e). Further, although the veteran did work for a number of years as a surgery scrub technician, there is no indication that his occupation involved the type of education, training or experience which qualifies him to comment on medical etiology. See 38 C.F.R. § 3.159(b). To the contrary, from descriptions provided by him and his former supervisor, it appears his occupation involved manually assisting medical professionals, and was gained primarily through on-the-job training (see report of July 2003 VA examination). As a layperson, therefore, his opinions as to medical etiology do not constitute medical evidence. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As to the sleep apnea, even assuming the veteran served in combat, he does not allege that he was treated in service for or diagnosed with sleep apnea or any associated symptoms. He was first diagnosed with sleep apnea years after service. Although his former spouse indicates that she noticed his sleep abnormalities shortly after she met him, this would have been several months after service, and the Board points out that sleep apnea is not a "chronic disease" subject to presumptive service connection when manifested to a compensable degree within one year of service. 38 C.F.R. § 3.309(a). In short, there is no event in service, and no indication of a continuity of symptoms since service. At most, there is an indication of symptoms beginning several months after discharge. Again, to the extent the veteran is relying on his own expertise to link his sleep apnea to service, the record does not show that he is a medical professional, and his opinion therefore does not service as an "indication" that the sleep apnea began in service. Given the lack of any "indication" that hypertension or sleep apnea is related to service, the Board finds that a VA opinion is not "necessary" as to the matter of whether either disorder is directly related to service. The Board notes that service connection is in effect for PTSD, as well as for hearing loss and tinnitus. The veteran does not contend that his hearing loss or tinnitus caused or chronically worsened his hypertension or sleep apnea. In one statement in August 2005, he alleged that his hypertension was secondary to PTSD, although prior to that time and since, he has maintained that the hypertension was either secondary to diabetes mellitus, or to exposure to herbicides in service. In any event, there still is no "indication" that hypertension or sleep apnea are related in some manner to PTSD or any other service-connected disorder in this case. The veteran has offered no observation which would suggest such a relationship. A medical opinion addressing that potential basis of entitlement is not warranted for the same reasons as discussed above. The Board lastly notes that in Schroeder v. West, 212 F.3d 1265, 1269-71 (Fed. Cir. 2000), the Federal Circuit concluded that once a veteran has properly made out a "well-grounded" claim for a current disability as a result of a specific in- service occurrence or aggravation of a disease or injury, VA's duty to assist pursuant to section 5107(a) attaches to the investigation of all possible in-service causes of that current disability, including those unknown to the veteran. The Board points out, however, that Schroeder was decided prior to the passage of the Veterans Claims Assistance Act (VCAA), which eliminated the concept of a "well-grounded" claim. More importantly, the VCAA resulted in the promulgation of 38 U.S.C.A. § 5103A, which, unlike the law and regulations in effect prior to the promulgation of the VCAA, specifically addresses when a VA examination or opinion is necessary in a claim. That statute specifically distinguishes between primary and secondary theories of causation. In the Board's opinion, Schroeder does not, in light of the specific criteria for requiring an examination or opinion established in 38 U.S.C.A. § 5103A, require VA to obtain a medical opinion in this case as to the question of primary service connection (or secondary service connection, with respect to disorders other than diabetes mellitus), even though the RO did obtain a medical opinion as to secondary service connection vis-à-vis diabetes mellitus. The Board notes that in discussing Schroeder, the Court in Robinson v. Mansfield, 21 Vet. App 545 (2008) noted several times that Schroeder spoke in terms of "well-groundedness." Id. at 552. The Board also points out that it is questionable whether the veteran was, in the first place, entitled to a VA opinion as to the relationship of his hypertension and sleep apnea to diabetes, given the lack of any "indication" of a relationship outside of the veteran's opinion. The Board notes that in Barr v. Nicholson, 21 Vet. App. 303, 311 (2007), the Court held that once VA undertakes the effort to provide an examination when developing a service- connection claim, even if not statutorily obligated to do so, VA must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. In this case, however, the veteran first raised his theory of primary service connection for hypertension, and secondary service connection for hypertension from PTSD, following the September 2004 VA examination. Under these circumstances, the Board finds that the examination report can not be reasonably described as deficient for failing to exercise clairvoyance as to what theories of entitlement a veteran may later raise. For the above reasons, the Board finds that further VA examination of the veteran with respect to his hypertension and sleep apnea claims is not necessary or otherwise required in this case. The Board notes that in his January 2006 appeal form, the veteran requested a hearing before a decision review officer. The requested hearing was scheduled for March 2006, but was apparently cancelled. The veteran has not requested another hearing in connection with this appeal. In sum, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Therefore, the veteran will not be prejudiced as a result of the Board proceeding to the merits of the claims. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). II. Service connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Service incurrence of hypertension during wartime service may be presumed if manifested to a compensable degree within one year of the veteran's discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. For the showing of 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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice- connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that VA amended its regulation pertaining to secondary service connection, effective from October 10, 2006. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation; specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. Because the new law appears more restrictive than the old, and because the veteran's appeal was already pending when the new provisions were promulgated, the Board will consider his appeal under the law in effect prior to October 10, 2006. See, e.g., Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (new regulations cannot be applied to pending claims if they have impermissibly retroactive effects). A. Hypertension Factual background The service medical records are silent for any complaints, findings or diagnosis of hypertension. Post-service medical records on file covering the period from August 1986 to April 2007 show that during a 1986 hospitalization, the veteran denied any history of diabetes mellitus or hypertension. A March 1995 chest X-ray study showed cardiomegaly following a recent motor vehicle accident, and a February 1998 chest X-ray study showed a borderline size of the cardiac silhouette. An April 2000 entry indicates that his history was negative for hypertension or diabetes mellitus. Treatment notes for 2002 show that the veteran was referred at one point for a blood pressure check, in light of recurring headaches. The records show that he was diagnosed with hypertension in 2004. A VA hospital report for March 2004 to May 2004 documents an Axis III diagnosis of diet-controlled diabetes; the accompanying records show that the veteran was actually considered to have borderline Type II diabetes, and was advised as to measures for maintaining lower blood sugar levels. His blood glucose level in January 2004 was elevated, and he was diagnosed with hyperglycemia. A September 2004 glucose tolerance test was normal, and his blood glucose level in January 2006 was within the identified reference range for normal, although blood glucose levels in April 2005 were elevated after he ingested a large amount of sugar-laden products. A January 2006 entry notes that the veteran was experiencing elevated sugar readings and spilling of ketones into his urine, but that he had no prior history of diabetes; the entry does not include a diagnosis of diabetes. In October 2006, he reported that he was using diabetes medications; the treatment records for that year do not indicate that any of his medications were issued for the control of diabetes. At a September 2004 VA examination, the veteran reported that he was diagnosed with diabetes in March 2004, but was not placed on medication. He noted that he was also found to be hypertensive at that time. The examiner diagnosed diabetes mellitus and essential arterial hypertension. In two January 2005 addendums to the September 2004 examination report, the examiner explained that in his opinion, the veteran did not have diabetes mellitus. He based this conclusion on the results of a three-hour glucose tolerance test, the results of which were not available at the time he wrote his original diagnosis. He indicated that the above test was normal, and that his review of other blood sugar tests in the record since August 2003 also did not support the presence of diabetes. He stated that the veteran was not even pre-diabetic. He concluded that the veteran's hypertension was not related to diabetes mellitus. At an October 2004 psychiatric examination, the veteran reported that he had Type 2 diabetes mellitus; the examiner did not confirm that disorder. Analysis Turning first to whether service connection is warranted for hypertension as secondary to diabetes mellitus, the Board notes that service connection was granted for diabetes mellitus in a December 2004 rating decision, but that service connection was severed in June 2005. As a result, service connection was in effect for diabetes mellitus for May 10, 2004, to September 1, 2005. Although service connection for diabetes is no longer in effect, given that service connection for the disorder was recognized during a portion of the instant appeal, the Board will consider whether secondary service connection is warranted. See generally, McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Although the veteran was thought to have a form of diabetes mellitus while hospitalized from March to May 2004, the entries for that period of hospitalization actually show that he was felt to be borderline diabetic, with sufficient control through dietary measures rather than through medication. Private and VA medical entries prior to that period of hospitalization show that he denied any history of diabetes. More importantly, his private and VA medical records since the 2004 hospitalization are consistently negative for any finding of diabetes. He was felt to be hyperglycemic in January 2004, but diabetes was not diagnosed. His blood glucose levels were elevated on two occasions in the records, but not at other times, and again, diabetes has not been diagnosed following the 2004 hospitalization, despite the veteran's report that he uses diabetes medication (an assertion not supported by his medication lists). Although the September 2004 VA examiner diagnosed diabetes mellitus, he did so while determinative test results remained pending. After reviewing those test results, he clarified that, in his opinion, the veteran did not have diabetes. He went on to explain that even the prior glucose tests described above did not show the presence of diabetes. He concluded that the veteran's hypertension was unrelated to diabetes mellitus. The Board finds the January 2005 addendum to be supported by the medical records as a whole (which are silent for any diagnosis of diabetes since May 2004), as well as by the glucose tolerance test results and other blood glucose tests on file. Although the veteran himself believes he has diabetes, as noted previously, the Board does not find that his former occupation establishes him as competent to render medical opinions, including as to diagnosis. Nor, in the Board's opinion, is diabetes a disease subject to lay diagnosis. See generally, Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Moreover, the January 2005 opinion concluded that the hypertension was not related to diabetes. The Board consequently finds that service connection for hypertension as secondary to diabetes mellitus is not warranted. The veteran also at one point contended that his hypertension was secondary to his service-connected PTSD. Notably, however, the only evidence suggesting that the PTSD, or the veteran's hearing loss or tinnitus, caused or chronically worsened his hypertension is the opinion of the veteran himself. None of his treating or examining physicians have commented on any relationship between the hypertension and the service-connected disorders. Given that the veteran, as a layperson, is not competent to offer a medical opinion linking his hypertension to a service-connected disorder, the Board finds that the preponderance of the evidence is against service connection for hypertension on a secondary basis. The veteran also contends that his hypertension is due to exposure to herbicides in service. The Board points out, however, that hypertension is not listed as a disease subject to presumptive service connection on an herbicide basis. See 38 C.F.R. § 3.309(e). Moreover, on June 12, 2007, and after reviewing the most recent study of the National Academy of Sciences, VA's Secretary did not find a basis for adding hypertension (or any other disorder not already included in the above regulation) to the list of disorders subject to a presumption of service connection based on exposure to herbicides. See 72 Fed. Reg. 32,395 (2007). Service connection on a presumptive basis (due to herbicide exposure) therefore is not warranted. The veteran is not precluded, however, from establishing service connection for a disease he believes is related to herbicide exposure, as long as there is proof of such direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). In this case, however, the service medical records are silent for hypertension in service or until decades thereafter. Nor, despite claiming to have been in combat, does the veteran allege that he had hypertension or any symptoms of hypertension in service or until many years after service. Moreover, there is no evidence, other than the veteran's own assertions, linking his hypertension to service, including to exposure to herbicides. As a layperson, his opinions concerning the etiology of his hypertension do not constitute competent medical evidence. Given that there is no evidence of hypertension in service or until more than a year after service, and no competent evidence linking the current hypertension to service or any event in service, the Board finds that service connection on direct basis, or as a chronic disease under 38 C.F.R. § 3.309(a) is not warranted. In short, there is no competent evidence of hypertension in service or until decades after service, and no competent evidence linking hypertension to service or to service- connected disability. As the preponderance of the evidence is therefore against the claim, the claim for service connection for hypertension is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). B. Sleep apnea Factual background The service medical records are silent for any reference to complaints, findings or diagnosis of sleep apnea. Post-service medical records on file covering the period from August 1986 to April 2007 first document the presence of sleep apnea in 1995; a sleep study in February 1995 indicated that the veteran had documented obstructive sleep apnea. The interim records until 2003 are silent for any mention of obstructive sleep apnea. Records for March 2003 show that he continued to use a CPAP device. During hospitalization in 2004, he was noted to use a CPAP in light of poor sleep hygiene and unspecified sleep disturbances. An August 2004 polysomnography report noted that he snored, and that he had obstructive sleep apnea. In a January 1999 statement, the veteran's former spouse, to whom he was married from 1971 to 1982, indicated that he would wake up shaking and soaked with perspiration; she did not mention any problems with breathing during sleep. In an August 2005 statement, she indicated that she would notice his frequent trouble sleeping, and noted that he would suddenly wake up gasping for air. As discussed in the prior section, a September 2004 VA examiner initially diagnosed diabetes mellitus, but in two January 2005 addendums, concluded that the veteran in fact did not have diabetes mellitus. He concluded that the veteran's sleep apnea therefore was not related to diabetes mellitus. Received in October 2005 were statements by two former girlfriends of the veteran, who collectively indicate that since knowing him from 1994, they can confirm that he snores and experiences difficulty breathing at night. In several statements beginning in August 2004, the veteran contends that his sleep apnea either is due to service, or to his diabetes. He reports that he met his former spouse several months after service, and that from the beginning of their relationship she had noticed that he would snore and stop breathing in his sleep. He indicates that he was issued a CPAP in 1995. Analysis As to the veteran's assertion that his sleep apnea is secondary to diabetes mellitus, as discussed at length in the prior section, the evidence as a whole shows that the veteran does not have diabetes mellitus. Moreover, the January 2005 addendum specifically concluded that the veteran's sleep apnea was unrelated to diabetes mellitus. For the same reasons as discussed previously, the Board finds the January 2005 addendum as to the presence of diabetes and any relationship to sleep apnea to be determinative in this case, and of greater probative value than the veteran's own statements as to the presence of diabetes and any relationship to sleep apnea. Nor is there any evidence even suggesting a relationship between the sleep apnea and any service-connected disorder. Consequently, service connection for sleep apnea on a secondary basis is not warranted. The veteran also contends that his sleep apnea originated in service because his former spouse noticed certain symptoms shortly after service. The Board again points out that the veteran does not contend that he was treated for, diagnosed with, or experienced symptoms of sleep apnea in service. The Board also points out that sleep apnea is not a "chronic" disease subject to presumptive service connection based on the proximity of its manifestation to discharge from service. Even assuming that the former spouse's recollection is credible, at most it establishes symptoms of sleep apnea several months after service. The Board points out that the veteran apparently was not diagnosed with a sleep disorder until decades later. In short, there is no evidence of sleep apnea in service, or until several months after service. The only evidence suggesting a relationship to service is that of the veteran's own opinions concerning etiology. As already discussed, the Board finds that he is a layperson with respect to matters of medical etiology, and that his opinions therefore are not competent. Given that there is no evidence of sleep apnea in service or until some point after service, and no competent evidence linking the current sleep apnea to service or to any service- connected disorder, the Board finds that the preponderance of the evidence is against the claim. The claim for service connection for sleep apnea is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). III. Increased rating In accordance with 38 C.F.R. §§ 4.1, 4.2 (2007) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the veteran's service-connected PTSD. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2007). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10 (2007). Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2007). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that consideration of staged ratings was appropriate in claims for an increased rating when the facts reflect distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart, 21 Vet. App. at 509-10. Factual background The veteran's period of service ended in November 1969. Service connection for PTSD was granted in March 2004, with an assigned rating of 10 percent. In June 2004, the RO assigned a temporary total evaluation for the period from March 1, 2004 to May 31, 2004; the RO assigned a 30 percent evaluation from June 1, 2004. The 30 percent evaluation has remained in effect since that time. In statements received in February 2003, the veteran's father and former spouse recounted symptoms they observed years before. In a statement received in February 2003, a former coworker and supervisor of the veteran indicated that he had little tolerance for authority, but generally got along with coworkers. The report of a July 2003 VA examination shows that the veteran complained of weekly nightmares, avoidance of reminders of service, avoidance of social contacts in general, and feelings of detachment from others except for family members. He also reported experiencing anger and sleep problems. He described a history of physical violence and impulsivity, as well as disregard for the safety of others and of the law. The veteran reported working from 1970 to 2002, primarily for the same employer. He indicated that he had good relationships with his girlfriend and with one child, his parents and a brother. He also noted that he had friends. He reported a remote history of suicidal ideation. Mental status examination showed no impairment in thought processes or communication, and no evidence or complaints of hallucinations or delusions. He displayed no inappropriate behavior or evidence of impaired activities of daily living or the ability to maintain minimal personal hygiene. He was oriented, with no memory impairment, and no evidence of obsessive or ritualistic behavior. No panic attacks were evidenced or reported, and he had no speech abnormalities. His mood was euthymic, and he displayed no unusual impulse control impairment. The examiner concluded that the veteran was functioning normally in areas such as self-care, schooling, family functioning, and recreational pursuits, but poorly in marital functioning. He noted that the veteran experienced some sleep impairment. The examiner assigned a Global Assessment of Functioning (GAF) score of 75. VA treatment records for 2003 to April 2007 show that in 2003, the veteran complained of anger outbursts and mood swings which he reported had occasionally resulted in loss of employment and damaged relationships at work. He reported that he recently chased a stranger with his car. He also reported a history of transient romantic liaisons and of failing to observe social norms. He indicated that he had friends and a girlfriend. The veteran noted that he avoided reminders of service, and experienced nightmares and occasional concentration problems. Mental status examination showed that he presented with good hygiene, and was oriented with no speech abnormalities or signs of psychosis. His thought processes were sometimes loose, but were logical. His judgment, memory, and concentration were intact. His mood ranged from euthymic to angry and mildly depressed. He denied suicidal or homicidal ideation. He was assigned GAF scores of 60. The records show that the veteran was hospitalized from March to May 2004 for his PTSD, with an admission GAF score of 35; shortly prior to his admission, his GAF score was identified as 47. His complaints at admission included irritability and trouble controlling his anger. He also reported nightmares, intrusive thoughts, social isolation, depression, interpersonal conflicts, and employment problems, and described a history of assaultiveness with resulting incarceration. The veteran indicated that he had held multiple jobs of short duration after service. He also noted that he had three friends. His symptoms improved during hospitalization, and by discharge he was euthymic and not considered at risk of imminent harm to himself or to others. His discharge GAF score was 75. Subsequent treatment records document complaints of intrusive thoughts, rage, nightmares, hyperarousal, lack of emotional control, and low energy levels. He consistently denied suicidal or homicidal ideation, but reported depression and anxiety. He reported marital difficulties and described himself as a loner, although he also indicated that he attends church. He reported that he once held a job for 9 years, and that he was now retired; he indicated that he experienced no complications at his former jobs because of his PTSD, but was told that he was very hostile. He indicated that he was motivated to seek treatment. Mental status examinations showed he presented with a neat appearance, with appropriate speech and affect. He was oriented with normal memory and fair judgment. He was tense at times. His mood ranged from euthymic to depressed. He denied hallucinations, delusions or disorganized thinking. He was assigned GAF scores of 65. The veteran attended a VA examination in February 2004. He reported experiencing nightmares twice each month, avoidance of service reminders, avoidance of large social gatherings, and feelings of detachment from people other than friends and family. He reported experiencing anger control problems. He reported positive relationships with his girlfriend, her family, and several of his own family members. He indicated that his anger problems had resulted in poor work success. He denied any history of suicide attempts or ideation. Mental status examination showed the absence of impaired thought processes or communication. There was no evidence or complaints of hallucinations or delusions, and no inappropriate behavior. There was no evidence of impairment in the ability to accomplish activities of daily living or to maintain minimal personal hygiene. He was oriented, with no memory impairment, and no evidence of obsessive or ritualistic behavior. No panic attacks or speech abnormalities were evident or reported. His mood was euthymic, and there was no unusual impulse control impairment. The examiner noted that the veteran had some sleep impairment, which he described as having a minimal impact on occupational and social functioning. The examiner noted that the veteran had no other symptoms impacting on functioning. He assigned the veteran a GAF score of 75. On an August 2004 VA Form 8940, the veteran reported that he discontinued working in 1995 due to obstructive sleep apnea. At an October 2004 VA examination, the veteran reported complaints including anger, isolation, and lack of motivation. He denied recent nightmares. He reported that he had been unemployed for three years. He explained that he initially stopped working because of physical injury, but now felt that his psychiatric disorder prevented employment. He reported that his current marriage was satisfactory, and that he had one friend. He denied a history of violence or suicide attempts, but reported that he was depressed. Mental status examination showed the absence of impaired thought processes or communication, or of any hallucinations, delusions, inappropriate behavior, suicidal or homicidal ideation, or obsessive or ritualistic behavior. He was oriented, but exhibited some absentmindedness. He denied panic attacks. The examiner assigned a GAF score of 60. With respect to employability, he noted that the veteran reported that he had lost confidence in himself since retiring after a work injury, and believed that his anger problems now prevented him from working. The examiner concluded that the veteran's unemployability was at least as likely as not a result of the emotional problems from his PTSD and personality disorders. In an August 2005 statement, the veteran's former spouse recalled witnessing the veteran's trouble sleeping, anger outbursts, and lack of concentration. At an April 2006 VA examination, the veteran complained of recurrent and distressing intrusive recollections, as well as hypervigilance and markedly diminished interest in significant activities. He also reported a restricted range of affect and sleep problems, as well as an exaggerated startle response and some irritability. He denied suicidal or homicidal ideations, or psychotic symptoms. He reported a compulsion of stealing small objects from flea markets. He indicated that he had a good relationship with his daughter, and that his spouse was his only friend; he explained that his only other friend had moved. He indicated that his last physical altercation was in 2003, and his last suicidal ideation in 1970. Mental status examination showed no impaired thought processes or communication, although he admitted to hearing his name called in the morning. There was no evidence or complaints of hallucinations or delusions, and no inappropriate behavior or evidence of impaired ability to perform activities of daily living or to maintain minimal personal hygiene. He was oriented, with no memory impairment. There was evidence of obsessive or ritualistic behavior by history, in that the veteran reported getting up several times during the night to check his doors. No panic attacks were evident or reported, and no speech abnormalities were present. His mood was depressed and his affect restricted. The examiner noted that there was impulse control impairment as evidenced by compulsive stealing, as well as sleep impairment. The examiner assigned a GAF score of 57. At an April 2007 VA examination, the veteran reported that his symptoms were generally of moderate severity, occurring on a daily to weekly basis. He indicated that he retired in 2001 because of work stress and problems with authority. He also noted that his experienced occasional trouble in his marital relationship. He noted that he maintained contact with daughter, but had minimal social contact outside of family. He denied suicidal ideation. Mental status examination showed no impairment of thought process or communication. He denied hallucinations or delusions, and displayed no inappropriate behavior. He denied current homicidal ideation or impairment of his ability to maintain activities of daily living and personal hygiene. He was oriented with no memory loss on testing. The examiner determined, however, that based on his reports of memory loss, the veteran had such loss with a mild impact on social and occupational functioning. There was no report or evidence of obsessive or ritualistic behavior, but the examiner noted that the reported kleptomania might have some compulsive overtones; he concluded that this consequently had a mild impact on social or occupational impact. There were no speech abnormalities or a reported history consistent with panic attacks. The veteran's mood and affect were dysphoric. He reported recurrent depressive feelings without self- harmful ideation. He also reported intermittent periods of anxiety which, in the examiner's estimation, had a mild to moderate impact. There were no impulse control issues evident, but based on the reported history of kleptomania and interpersonal difficulties, he concluded that the veteran had some impulse control issues productive of a moderate impact. The examiner also concluded that there was a history of sleep problems and hypervigilance with a moderate impact. The examiner assigned a GAF score of 62. In several statements on file, the veteran reported experiencing poor social and family relationships. He reported experiencing trouble with expressing himself, and exhibiting poor judgment, as evidenced by shoplifting and driving without a license. He also reported memory loss and frequent panic attacks. Analysis The RO evaluated the veteran's PTSD as 30 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2007). That code provides that a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for 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. Review of the record shows that, although the veteran remained steadily employed at the same job for a number of years before retiring (despite his report in 2004 that his job history was more varied), he did experience interpersonal conflicts with persons at work, as documented by the statement of a former coworker/supervisor. More recently, he has suggested that these interpersonal conflicts were partially responsible for his retirement, although earlier he reported that a physical injury prompted his retirement, with his psychiatric disability impacting his motivation for seeking further employment. What is clear, however, is that the veteran does have a long history of interpersonal conflicts, some of which have involved physical confrontations. His friendships are currently limited to his spouse and his daughter, although he does engage in social activities such as attending church. The record also reflects that the veteran's psychiatric symptoms include nightmares, intrusive thoughts, irritability and anger outbursts, depression, and some impulse control issues, all experienced on a fairly regular basis. His GAF scores (other than when hospitalized for acute decompensation) have ranged as low as 57. GAF scores ranging between 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). See generally, Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p. 32). In the Board's opinion, the above evidence shows that the veteran's PTSD has been productive of occupational and social impairment such as to cause him difficulty in establishing and maintaining effective work and social relationships. Accordingly, the Board finds that a 50 percent evaluation for PTSD is warranted. With respect to whether the veteran is entitled to a rating in excess of 50 percent for PTSD, the Board notes that he has not demonstrated occupational and social impairment due to such symptoms as suicidal ideation, abnormal speech, near continuous panic, perceptual or cognitive impairment, grossly inappropriate behavior, or impairment in his ability to perform his activities of daily living. Although the veteran experiences recurrent depression, he has not experienced suicidal ideation for decades, and never a suicide attempt. His anxiety symptoms were not, in the opinions of his examiners, consistent with panic attacks. Although the veteran reports trouble with finding words, and at one point was loose in his thought processes, his speech has otherwise been consistently described as normal, with no evidence of a psychotic thought process or disorientation. Even when describing the experience of hearing his name called in the morning, his VA examiner found no evidence of hallucinations or delusions. Although the veteran apparently engages in kleptomania, his examiners have described the impact on his social and occupational functioning as no more than moderate. He admits that he has not suffered legal consequences from his tendencies. Moreover, while the veteran has reported a history of numerous physical altercations, he has not engaged in one since 2003. Moreover, no impairment of impulse control was evident on VA examinations, and his examiners have described the resulting impact on functioning as no more than moderate. The veteran has consistently denied homicidal ideation, and neither his treating nor examining physicians have suggested that the veteran is in persistent danger of harming himself or others. Although the veteran reports that he no longer is able to work because of interpersonal conflicts resulting from his anger, the Board points out that he retired after a physical injury, and after a prolonged period of employment at the same facility. A former supervisor noted that the veteran actually got along well with his coworkers in general, and the veteran himself occasionally admits that he did not leave his last job because of any conflicts. The Board acknowledges that the October 2004 examiner concluded that the veteran's unemployability was at least as likely as not a result of the emotional problems from PTSD and personality disorders. The Board points out, however, that this opinion is inconsistent with the mental status findings noted on that examination, as well as with the GAF score assigned by that examiner. He assigned a GAF score of 60, which is consistent with moderate symptoms or moderate difficulty in social, occupational, or school functioning. The other GAF scores assigned (except during the period of decompensation for which the veteran has already been assigned a temporary total evaluation) ranged from 57 (also reflective of moderate difficulty) to 75. Moreover, although the veteran reports that he now only has his spouse and daughter as friends, the record shows that his circle of friends has diminished based on their relocation, rather than his psychiatric impairment. He still attends church without any reported problems, and interacts with his spouse's family. In short, the evidence does not even remotely suggest the presence of total occupational or social impairment. Nor, given the consistent assessment of even his more serious symptoms as productive of no greater than moderate impairment (with assigned GAF score consistent with this assessment), is there even occupational or social impairment with deficiencies in most areas. Accordingly, the Board concludes that an evaluation in excess of 50 percent for PTSD is not warranted. Accordingly, the veteran is entitled to a 50 percent evaluation, but not higher, for his service-connected PTSD. The Board has considered whether a rating higher than 50 percent is warranted for any discrete period during the course of this appeal. As noted previously, the veteran was assigned a temporary total evaluation to compensate him for his period of decompensation from March to May 2004. The records have otherwise been remarkably consistent in demonstrating no more than a 50 percent level of impairment. The Board therefore finds that the veteran is not entitled to assignment of a rating higher than 50 percent rating for any portion of this appeal. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board lastly has considered whether the case should be referred for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1) (2007). Although the veteran is currently unemployed, as discussed previously, the record shows that he nevertheless had a steady work history and appears to have retired on account of a physical injury. He may be in receipt of disability benefits from the SSA, but that agency has not been able to locate any records for him. The veteran admittedly did not suffer disciplinary consequences for interpersonal conflicts at work when he was employed (or at least not recently), and his examining physicians have assigned him GAF scores that do not suggest marked interference with employability. In addition, there is no evidence that the veteran's psychiatric disability has necessitated frequent periods of hospitalization or that the manifestations of the disability are unusual or exceptional. Therefore, the Board finds that the criteria for submission for an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 237 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). IV. Total rating based on individual unemployability due to service-connected disabilities Under the applicable criteria, total disability ratings for compensation based upon individual unemployability 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 disabilities, provided at least one disability is ratable at 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(a) (2007). In the instant case, even with the increase in the evaluation assigned the PTSD to 50 percent, the veteran does not meet the schedular criteria for a total disability rating based on individual unemployability. The veteran's PTSD is 50 percent disabling. His other service-connected disorders are tinnitus and hearing loss, evaluated as, respectively, 10 percent and noncompensably disabling. His combined disability rating is 60 percent, which does not meet the minimum schedular criteria for TDIU under 38 C.F.R. § 4.16(a). The Board notes that even with consideration of the veteran's diabetes mellitus for the short period during which service connection was in effect, the veteran's combined disability rating would still be 60 percent. Even when the percentage requirements are not met, however, entitlement to a total rating on an extraschedular basis may nonetheless be granted in exceptional cases when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. §§ 3.321(b), 4.16(b) (2007). Consideration may be given to a veteran's education, special training, and previous work experience, but not to his age or to the impairment resulting from nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2007); see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether a veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. In this case, the evidence on file does not show that he is unable to work due to his service-connected disorders. The veteran has been inconsistent as to the reason for his retirement, but did originally report that he stopped working because of a physical injury, and after employment for many years. His former supervisor noted that he largely got along with his coworkers, and the veteran denied any disciplinary problems when working. Although the October 2004 examiner suggested that the veteran's unemployment status was due to psychiatric symptoms, the examiner himself reported largely normal mental status findings, and assigned a GAF score that is not even remotely suggestive of the inability to obtain or maintain employment. Moreover, the competent medical evidence does not support a finding that the veteran's service-connected disorders render him unemployable. Other than for the several month period in 2004 when he was hospitalized for decompensation (after he had already stopped working), the veteran's mental status findings did not suggest more than moderate symptoms. The GAF score assigned by his treating and examining physicians, which ranged from 57 to 75, also reflected no more than moderate impact on occupational functioning. The veteran has never contended, nor does the evidence suggest, that the veteran's tinnitus or hearing loss interfered with employment in any manner. The Board notes that he believes his sleep apnea plays a role in his unemployment status; as discussed previously, service connection is not warranted for that disorder. As noted above, the question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. The medical evidence does not show the veteran to be unemployable due solely to his service-connected disabilities. Although the Board does not doubt that the veteran's service- connected disabilities have some effect on his employability, the preponderance of the evidence does not support his contention that his service-connected disabilities, and his PTSD in particular, are of such severity so as to preclude his participation in any form of substantially gainful employment. Similarly, there is no evidence that the veteran's disability picture is so exceptional or unusual so as to render inapplicable the schedular standards and insufficient evidence that the veteran is unable to secure substantially gainful employment by reason of service-connected disability. Therefore, referral to the Director, Compensation and Pension Service for extra-schedular consideration is not warranted. 38 C.F.R. § 4.16(b) (2007). Accordingly, the Board finds that the evidence does not demonstrate that his service-connected disabilities, when considered in association with his education and occupational background, render him unable to secure or follow a substantially gainful employment. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection, to include on a secondary basis, for hypertension is denied. Entitlement to service connection, to include on a secondary basis, for sleep apnea is denied. Subject to the controlling regulations applicable to the payment of monetary benefits, a 50 percent rating for PTSD is granted. Entitlement to a total rating based on individual unemployability due to service-connected disabilities is denied. ______________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs