Citation Nr: 1018389 Decision Date: 05/18/10 Archive Date: 06/04/10 DOCKET NO. 08-17 024 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Ft. Harrison, Montana THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome (CFS). 2. Entitlement to service connection for irritable bowel syndrome (IBS). 3. Entitlement to an initial evaluation in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD) with depression. 4. Entitlement to a total rating based on individual unemployability due to service connected disabilities. REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty from May 2001 to May 2005. This matter comes to the Board of Veterans' Appeals (Board) from June and November 2007 rating decisions. Regarding PTSD, the Veteran is contesting the initial disability rating assigned. Because the Veteran has appealed the RO's determination at the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). With respect to CFS and IBS, the Veteran is appealing the denial of service connection. It is noted that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the record raises a question of whether the Veteran is unemployable due his service-connected PSTD; as such, a claim for a TDIU has been listed on the title page. The Veteran cancelled his scheduled travel Board hearing that was to take place in August 2009. The Board observes that in March 2009, the Veteran stated orally over the telephone that he did not wish to pursue his appeal. He was asked to state so in writing, but he has failed to comply with the request. As such, the appeal continues before the Board. FINDINGS OF FACT 1. The Veteran is not shown to be suffering from CFS; fatigue is shown to be a symptom of his psychiatric disorders. 2. The Veteran is not shown to be suffering from IBS; diarrhea is not shown to be a manifestation of undiagnosed illness, and it is not shown to be the proximate result of medication used to treat the Veteran's service-connected PTSD and depression. 3. The Veteran's PTSD with depression is manifested by no more than moderate symptomatology and full orientation, normal thought processes, unimpaired speech, good insight, and satisfactory judgment. 4. Service connection is in effect for PTSD, rated as 30 percent disabling; degenerative disc disease of the thoracolumbar spine, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling, and left ear hearing loss, rated as noncompensably disabling. The combined rating is 40 percent. 5. The Veteran's service-connected disabilities do not render him unable to gain and retain substantially gainful employment. CONCLUSIONS OF LAW 1. CFS was not incurred in or as a result of the Veteran's active duty service, is not presumptively linked thereto, and is not proximately due to a service-connected disability. 38 U.S.C.A. §§ 1110, 1117, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2009). 2. IBS was not incurred in or as a result of the Veteran's active duty service, is not proximately linked thereto, and is not proximately due to a service-connected disability. 38 U.S.C.A. §§ 1110, 1117, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2009). 3. The criteria for entitlement to a disability evaluation in excess of 30 percent for the service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2009). 4. The criteria for the assignment of a total rating based on individual unemployability due to service connected disabilities are not met. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Criteria Service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Service connection may also be established for a chronic disability resulting from an undiagnosed illness which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d)(2). A 'qualifying chronic disability' means a chronic disability resulting from any of the following (or any combination of any of the following): an undiagnosed illness; a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms; and any diagnosed illness that the Secretary determines. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a) (1) (i). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2-5). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). Compensation shall not be paid under this section if: (1) there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). A claim of service connection must be accompanied by medical evidence establishing that the claimant currently has the claimed disability. Absent proof of a present disability, there can be no valid claim. See, e.g., Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (38 U.S.C. § 1110 requires current symptomatology at the time the claim is filed in order for a veteran to be entitled to compensation); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997) (38 U.S.C. § 1131 requires the existence of a present disability for VA compensation purposes). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (reasonable doubt to be resolved in veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. CFS On report of medical history completed in April 2001 for enlistment purposes, the Veteran noted no abnormalities, and no significant abnormalities were found pursuant to the corresponding medical examination. In May 2003, the Veteran completed a post-deployment medical questionnaire wherein he denied all listed symptomatology. In a dental health questionnaire completed in May 2001 and resigned in August 2002, February 2004, and February 2005, the Veteran denied all listed symptoms and disabilities. In June 2006, the Veteran reported, in pertinent part, headaches; swollen, stiff, or painful joints; muscle aches; and unrefreshing sleep. In an October 2006 written statement, the Veteran's brother indicated, inter alia, that the Veteran had significant sleep problems. In a written statement dated that month, the Veteran's mother recounted that the Veteran could not sleep and that when sleep did come, it was punctuated by nightmares. A December 2006 psychiatric examination report indicated that the Veteran was able to sleep when taking sleeping pills. He was also said to be engaged in habitual binge drinking. Other records reflect abuse of prescription pain medication and other narcotics abuse. On April 2007 VA PTSD examination, the Veteran, in relevant part, complained of a lack of energy. On October 2007 VA medical examination, the Veteran claimed that he suffered from CFS due to trash heap exposure in the Persian Gulf region. The Veteran denied a diagnosis of CFS but indicated that he was exposed to burning trash pits in Iraq and was told by his representative that toxins from the blazing trash pits caused CFS. The Veteran reported being tired upon waking especially if he had a poor night's sleep. He indicated that he felt tired after exercise and that he had a sleep disturbance. He stated that he missed work as a result of being too tired. He denied low-grade fevers, palpable or tender cervical or axillary lymph nodes, generalized muscle aches or weakness, migratory joint pains, and neuropsychological symptoms. The examiner indicated that the Veteran's stated symptomatology did not meet the criteria for a diagnosis of CFS, as he denied low-grade fevers, flu-like symptoms, migratory joint pains, and other symptoms associated with CFS. The examiner noted that the Veteran had been diagnosed with two conditions known to cause fatigue, namely depression and insomnia. As well, the examiner observed that the symptoms of fatigue began at around the time in which serious alcohol and drug abuse began. The examiner noted that alcohol and cocaine abuse were known to cause fatigue. The examiner opined that the Veteran did not have CFS and that his fatigue was related to depression and insomnia and aggravated by alcohol and drug abuse. In a December 2008 VA examination report, the examiner noted the Veteran's pre-service traumatic brain injury (TBI) that occurred after the Veteran fell off a ladder. The examiner opined that the Veteran's complaints of insomnia and fatigue were not likely related to the pre-service TBI. In March 2009, a VA examiner opined that it was "as likely as not" that the Veteran's complaints of insomnia and fatigue were related to the service-connected PTSD. The examiner indicated that he would be compelled to resort to speculation regarding whether insomnia and fatigue were related to a history of a mild TBI and/or substance abuse. At the outset, the Board observes that direct service connection for CFS cannot be granted because, while the Veteran may well suffer from fatigue, he has not been diagnosed with the foregoing condition. A current disability is a necessary (if not sufficient) condition for the granting of service connection. 38 C.F.R. § 3.303; Gilpin, supra. Because CFS is not a condition from which the Veteran presently suffers, service connection for it cannot be granted on a direct basis. Id. To the extent that the Veteran asserts that his fatigue is a manifestation of undiagnosed illness, the claim fails. Service connection for the Veteran's alleged fatigue cannot be granted as manifestations of undiagnosed illness because his fatigue has been associated with known causes. The Veteran's fatigue is likely due to insomnia as well as to PTSD and/or depression. Because known factors have caused the complained of symptomatology, service connection for the symptomatology as due to undiagnosed illness is precluded. 38 C.F.R. § 3.317. The Board will now examine whether service connection for fatigue is warranted on a secondary basis. 38 C.F.R. § 3.310. As discussed above, CFS itself has not been shown. It appears that fatigue is a symptom of the service-connected PTSD with depression. Service connection is not available for symptoms. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (holding that symptoms alone, without a diagnosed or identifiable underlying malady or condition, do not in and of themselves constitute a disability for which service connection may be granted). Rather, the Veteran's fatigue may well be considered in connection with his service- connected mental disorder. The fatigue he experiences, however, is not a disability in and of itself. Id. Because the symptom of fatigue does not constitute an independent disability, service connection for it cannot be granted on any basis to include as secondary to another service- connected disability. 38 C.F.R. § 3.310; see also 38 C.F.R. § 3.303. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. IBS The service treatment records do not reflect complaints or diagnoses consistent with IBS. On October 2007 VA medical examination, the Veteran reported that diarrhea had its onset about six months after he arrived in Iraq in 2004. He reported current symptoms of diarrhea two to three times a week interspersed with constipation and days with normal bowel movements. The Veteran also reported sharp gas pains. The Veteran denied such symptoms as weight loss, mucous in the stool, upper abdominal discomfort after eating, nausea, etc. The examiner noted a negative clinical examination. The abdomen was with normal bowel sounds with no evidence of cramping, bloating, or pain. There was no objective evidence of malnutrition or anemia. In short, the examiner stated, "No evidence of claimed IBS on examination." The Veteran, according to the examiner, reported bouts of diarrhea three to five times a week but denied symptoms, which according to the authoritative medical literature, were present with a diagnosis of IBS. These symptoms included mucous in the stool, abdominal distention, upper abdominal discomfort after eating, straining for normal consistent stools, feelings of incomplete evacuation, nausea, and vomiting. Thus, pursuant to an examination of the Veteran, review of the record, and a study of the pertinent medical literature on IBS, and based upon the Veteran's reported symptomatology, the examiner concluded that the Veteran did not suffer from IBS. The examiner observed, moreover, that diarrhea was a common side effect of Cymbalta, an antidepressant the Veteran had used. A December 2008 VA medical opinion indicated that the current medical literature reflected that noninfectious causes of diarrhea included drugs. The drugs most noted for the side effect of diarrhea were cholinergic agents and magnesium- containing antacids. Some of the medications the Veteran took for pain, addiction, and for PTSD and/or depression included the side effect of diarrhea. The examiner opined that the Veteran's complaints of diarrhea were at least as likely as not related to some of the drugs he took for mental health issues and for opioid withdrawal. Based on the foregoing evidence, service connection for IBS cannot be granted because the Veteran does not suffer from IBS. 38 C.F.R. § 3.303; Gilpin, supra. As well, it appears from a review of the record that diarrhea is not a manifestation of undiagnosed illness because it has been attributed to known causes to include withdrawal from opioids and/or opiates and to side effects of psychotropic medication. 38 C.F.R. § 3.317. The Veteran has been awarded service connection for PTSD and depression. For these acquired psychiatric disorders, he has taken a myriad of psychotropic medications to include Paxil, Wellbutrin, Effexor, Celexa, trazodone, mitrazapine (Remeron), Depakote, and Cymbalta. He has also taken Zoloft without a prescription. His compliance with medication has been inconsistent at best, and he stopped taking some of the medications due to a variety of side effects such as delayed orgasm in the case of Paxil. Some of the medications listed above such as Paxil, trazodone, Zoloft, and Cymbalta have been said to cause diarrhea. Despite the foregoing, service connection for a disability manifested by diarrhea cannot be granted as secondary to medication taken for the service- connected psychiatric disorders because it is uncertain which, if any, he takes on a regular basis due to spotty compliance and general dissatisfaction with certain claimed side effects. Furthermore, not all of the above mentioned medications cause diarrhea. Thus again, because it is uncertain that the Veteran currently takes medication for his service-connected psychiatric PTSD with depression or that he uses medication that is known to include diarrhea as a side effect, service connection for a disability manifested by diarrhea as secondary to service-connected PTSD and depression is denied. 38 C.F.R. § 3.310. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision pursuant to any theory of entitlement. Increased Ratings Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3 (reasonable doubt to be resolved in veteran's favor). In Gilbert, the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany, 9 Vet. App. at 519. The consequences of failing to report for a VA examination are outlined in 38 C.F.R. § 3.655. This section provides: (a) General. When entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination, or reexamination, action shall be taken in accordance with paragraph (b) or (c) of this section as appropriate. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. For purposes of this section, the terms "examination" and "re-examination" include periods of hospital observation when required by VA. (b) Original or re-opened claim, or claim for increase. When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with any other original claim, a re-opened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. The Veteran has a long established history of failing to appear for medical appointments without prior cancellation. In connection with his claim for increase herein, he neglected to report for two VA mental health examinations in December 2008. These examinations were scheduled to determine the current nature and severity of the Veteran's service-connected PTSD with depression. Neither the Veteran nor his representative has provided an acceptable explanation for this failure to appear. As noted above, when a claimant fails, without good cause, to report for an examination scheduled in conjunction with an original claim, the claim shall be decided based on the evidence of record. The Veteran's for increase herein is an original claim. See 38 C.F.R. § 3.655. See Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating). The Veteran has not furnished an explanation for his failure to report. As such, good cause is not shown, and the issue of entitlement to an increased rating for PTSD will be decided based on the evidence of record. The Veteran's service-connected PTSD has been rated 30 percent disabling by the RO under the provisions of Diagnostic Code 9411. 38 C.F.R. § 4.130. PTSD is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. The pertinent provisions of 38 C.F.R. § 4.130 relating to rating psychiatric disabilities read as follows: A 100 percent rating is assigned 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. A 70 percent rating is assigned 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 50 percent rating is assigned 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 effective work and social relationships. A 30 percent rating is assigned 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, and mild memory loss (such as forgetting names, directions, recent events). A 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A no compensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication 38 C.F.R. § 4.130, Diagnostic Code 9411 (2009). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM- IV), p. 32). GAF scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores of 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). The Veteran has a long history of extensive substance abuse that includes the abuse of prescription medication, illegal narcotics, and alcohol. As a result, he has attended several rehabilitation programs. A November 2006 private psychiatric examination report indicates that the Veteran began to use narcotic pain relievers when he returned from Iraq. At that time, he also began to drink heavily. As to depression, the Veteran described sadness, a lack of interest, low concentration, and variable appetite, and passive suicidal ideation without a plan or history of attempts. On mental status examination, the psychiatrist noted that the Veteran was neatly dressed and displayed good eye contact. His thought processes were linear, his insight was good, and his judgment was also assessed as good. The Veteran displayed a somewhat subdued affect. The diagnosis was of major depressive disorder, single episode, as well as PTSD. The examiner assigned a GAF score of 60. A December 2006 private psychiatric evaluation report reflected heavy drinking. However, a new medication caused an improved mood. Objectively, the psychiatrist observed that the Veteran was neatly dressed. He displayed good eye contact. His thought process was linear, and his insight and judgment were both good. The psychiatrist diagnosed major depressive disorder single episode, PTSD, and alcohol abuse and assigned a GAF score of 60. A January 2007 VA progress note indicated that the Veteran was using steadily increasing quantities of addictive prescription medication to include OxyContin as well as street drugs. The examiner diagnosed PTSD/depression and polysubstance abuse. On April 2007 VA psychiatric examination, the Veteran reported constant depression and recent weight gain. He had trouble making decisions and complained of lacking energy. Regarding PTSD, the Veteran reported monthly nightmares, flashbacks brought on by loud noises, and daily thoughts of combat. He spoke of an exaggerated startle response and was hypervigilant. He indicated that he had lost interest in activities that were previously enjoyable. He was estranged from colleagues and socially isolated, but he admitted social contact with "bad" people. He had no hobbies or leisure activities. The Veteran reported three jobs since 2005 one of which he quit in anger. Objectively, the Veteran was oriented in all spheres. His speech was clear and coherent, and there were no signs of a thought disorder. Dress, hygiene, concentration, memory, and behavior were all acceptable. The diagnosis was of PTSD and depressive disorder not otherwise specified. The examiner assigned a GAF score of 57 and opined that the Veteran was able to handle his own finances and assessed that there were no occupational impediments. In February 2008, the Veteran presented seeking VA inpatient opioid addiction treatment because outpatient programs were ineffective. The Veteran reported being self employed as a carpenter. Upon asking the Veteran about his mental state, health history, military background, and substance abuse patterns, the examiner diagnosed PTSD and opioid dependence and assigned a GAF score of 50. On April 2008 VA PTSD examination, the Veteran arrived promptly. He was polite and courteous, and presented well socially. He displayed no unusual behaviors or mannerisms. He expressed himself well during the interview. The Veteran was at least of average intelligence, and no cognitive impairment was perceived. The Veteran was well groomed, hygiene was good, and he was alert and oriented. The Veteran described ongoing problems with the abuse of prescription medication. The Veteran indicated that he had been unemployed since 2007. Apparently, he had a hard time working because he was unreliable and had difficulty arriving on time. The Veteran spoke of social anxiety and complained of having few friends. The Veteran indicated that he had stopped mental health and substance abuse treatment but stated that he would start again soon. He did not yet have an appointment, and the examiner indicated that the Veteran had missed a recent psychiatric treatment appointment. The Veteran described symptoms consistent with PTSD to include night sweats and difficulty sleeping. He was "jumpy" and had an exaggerated startle response. The Veteran was hypervigilant and uneasy in crowds. He complained of intrusive thoughts. Objectively, voice and speech were normal. The Veteran maintained good eye contact, and his affect was mildly blunted but reactive. The Veteran's mood was anxious, irritable, and dysphoric. There was no impairment in cognition or concentration. Memory was intact, and the Veteran's thinking was unimpaired. The examiner diagnosed PTSD. The examiner indicated that it was unclear whether the Veteran's opioid dependence was in remission. The examiner assigned a GAF score of 55 and indicated that PTSD symptoms would have some impact upon occupational and social functioning and occasional decreases in work efficiency. It was likely, according to the examiner, that addiction issues also had an impact upon work performance. On January and February 2009 addenda to the foregoing examination report, the VA examiner opined that the Veteran's opioid dependence was not likely due to his service-connected PTSD. In March 2009, the examiner opined that the Veteran's complaints of insomnia and fatigue were probably symptoms of the service-connected PTSD A review of the evidence suggests that a 50 percent rating for the Veteran's service-connected psychiatric disorders is not warranted at any time during the appellate period. 38 C.F.R. § 4.130, Diagnostic Code 9411; Fenderson, supra. Initially, the Board notes that some of the impairment in social and occupational functioning is due to the Veteran's substance abuse problems. The Board's discussion herein is focused on the impact of PTSD and depression upon the Veteran's occupational and social impairment. Consistently, his thought processes, speech, mannerisms, memory, cognition, judgment, insight, and behavior have been assessed as normal. Although the Veteran has described irritability, chronic impulse control problems are not apparent from the record. Furthermore, the Veteran's GAF scores have hovered between 50 and 60, reflecting mainly moderate symptomatology. Thus, while the Veteran has exhibited difficulty establishing effective work and social relationships, the serious symptoms associated with a 50 percent evaluation for psychiatric disorders are simply absent. As such, a 50 percent evaluation for the Veteran's PTSD is denied at any time during the appellate period. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2009). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. In denying the claim for a higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD and depression with the established criteria found in the rating schedule for psychiatric disorders shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for his PTSD. Indeed, it does not appear from the record that he has been hospitalized at all for that disability. Additionally, there is not shown to be evidence of marked interference with employment due to the disability. The Veteran has had problems with employment, but appears to take on carpentry projects independently. There is nothing in the record which suggests that PTSD markedly impacted his ability to perform his job. Moreover, there is no evidence in the medical records of an exceptional or unusual clinical picture. There is nothing in the record to indicate that this service- connected disability on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (the disability rating itself is recognition that industrial capabilities are impaired). The Board has determined that referral of this case for extra- schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. The Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. TDIU In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU is part and parcel of an increased- rating claim when the issue of unemployability is raised by the record. In this case, the issue of unemployability is raised by the record. The Veteran has consistently reported that he is not currently employed, particularly when referencing his PTSD. Pursuant to Rice, the issue of unemployability is raised by the record. A Veteran will be entitled to a TDIU upon establishing he is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2009). Consideration may be given to his level of education, any special training, and previous work experience in making this determination, but not to his age or impairment from disabilities that are not service connected (i.e., unrelated to his military service). See 38 C.F.R. §§ 3.341, 4.15, 4.16, 4.19 (2009). To qualify for a total rating for compensation purposes, the evidence must show (1) a single disability rated as 100 percent disabling; or (2) that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities - provided there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16(a). Service connection is in effect for PTSD, rated as 30 percent disabling; degenerative disc disease of the thoracolumbar spine, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling, and left ear hearing loss, rated as noncompensably disabling. The combined rating is 40 percent. As such, the Veteran's combined disability rating fails to meet the percentage requirements of section 4.16. However, even if the ratings for a Veteran's disabilities fail to meet the first two objective bases upon which a permanent and total disability rating for compensation purposes may be established, the Veteran's disabilities may be considered under subjective criteria. If the Veteran is unemployable by reason of his disabilities, occupational background, and other related factors, an extraschedular total rating may also be assigned on the basis of a showing of unemployability, alone. See 38 C.F.R. § 4.16(b). The evidence of record shows that the Veteran's service- connected disabilities alone do not render him unemployable. Rather, the record suggests that the Veteran's unemployment is due to alcohol and substance abuse which are not secondary to his PTSD. The medical reports show that the Veteran is continuously admitted into detox programs and substance abuse programs. As demonstrated above, the reports also reflect that a rating in excess of 30 percent is not warranted for the Veteran's PTSD and the Veteran's symptoms are adequately contemplated in the assigned rating. See VA medical reports dated from 2008 through 2009. As noted in 2008, the Veteran's addiction issues impact his ability to work. This is also illustrated in the Veteran's admissions into detox programs. The evidence also fails to show that the Veteran's low back disability, tinnitus or left ear hearing loss rendered him unemployable. Thus, the matter is denied. Veterans Claims Assistance Act of 2000 (VCAA) As provided for by VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). 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); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service- connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Notice consistent with the Court's holding in Dingess was provided on several occasions to include in August 2007. The VCAA duty to notify was satisfied by way of letters sent to the Veteran in September 2006, January 2007, August 2007, and October 2007 that fully addressed all three notice elements and was sent prior to the initial AOJ decision in this matter. The letters informed the Veteran of what evidence was required to substantiate the claims and of the Veteran's and VA's respective duties for obtaining evidence. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination or examinations when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the service personnel records, service treatment records, VA clinical records, and private medical records. The Veteran was afforded VA medical examinations in connection with his claims. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for CFS is denied. Service connection for IBS is denied. An increased rating for service-connected PTSD with depression is denied. Entitlement to a total rating based on individual unemployability is denied. ______________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs