Citation Nr: 1016966 Decision Date: 05/06/10 Archive Date: 05/19/10 DOCKET NO. 06-30 884 ) DATE ) MERGED APPEAL ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for gout. 2. Entitlement to an initial rating greater than 50 percent prior to June 12, 2004 and greater than 70 percent from June 12, 2004 to May 3, 2007 for posttraumatic stress disorder (PTSD). 3. Entitlement to an effective date earlier than June 12, 2004 for the grant of total disability based on individual unemployability (TDIU). 4. Entitlement to an effective date earlier than June 12, 2004 for the grant of eligibility to Dependents' Educational Assistance (DEA). 5. Entitlement to special monthly compensation by reason of being in need of the regular aid and attendance or on account of being housebound. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Esquire ATTORNEY FOR THE BOARD C. J. Houbeck, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1968 to September 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2001, January 2005, and September 2008 Regional Office (RO) in Detroit, Michigan rating decisions. The January 2001 rating decision granted service connection for PTSD and assigned a 50 percent rating, effective April 18, 2000. The January 2005 rating decision denied service connection for gout. The September 2008 rating decision increased the Veteran's rating for PTSD to 70 percent, effective June 12, 2004, and 100 percent, effective May 3, 2007; granted TDIU, effective June 12, 2004; found eligibility for DEA, effective June 12, 2004; and denied entitlement to special monthly compensation based on aid and attendance or on account of being housebound. With respect to the 100 percent rating for PTSD, effective May 3, 2007, this decision was a complete grant of benefits with respect to this timeframe. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Therefore, the issue of an increased rating for PTSD from May 3, 2007 is not currently on appeal before the Board. With respect to the 70 percent rating for PTSD, effective June 12, 2004, regardless of the RO's actions, the issue remains before the Board because the increased rating is not a complete grant of the maximum benefits available. See AB v. Brown, 6 Vet. App. 35 (1993). The issue of entitlement to service connection for gout was remanded by the Board for additional development in December 2008. The issue is once again before the Board, having been merged with the other issues noted above. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a current diagnosis of gout that is etiologically related to a disease, injury, or event in service, to include service-connected PTSD. 2. Prior to June 12, 2004, the Veteran's PTSD was manifested by occupational and social impairment which most nearly approximates reduced reliability and productivity; however, occupational and social impairment with deficiencies in most areas was not shown. 3. Between June 12, 2004 and May 3, 2007, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas; however, total occupational and social impairment was not shown. 4. Prior to June 12, 2004, the Veteran did not have a single disability ratable at 60 percent or more, or at least one ratable at 40 percent or more with a combined rating to 70 percent or more; and the evidence does not otherwise establish that the Veteran was unemployable solely due to his service connected disability. 5. Basic eligibility for entitlement to DEA benefits is not established prior to June 12, 2004 because the Veteran was not determined to be permanently and totally disabled due to service-connected disabilities prior to that date. 6. The preponderance of the evidence does not establish that the Veteran's service-connected disabilities render him so helpless as to require the regular aid and attendance of another person to perform personal care functions of everyday living or to protect himself from the hazards and dangers incident to the daily environment. 7. The Veteran does not have a single service-connected disability rated as 100 percent disabling and is not shown to be permanently housebound as a result of his service- connected disabilities. CONCLUSIONS OF LAW 1. Gout was not incurred in or aggravated by service, to include as a result of service-connected PTSD. 38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2009). 2. Prior to June 12, 2004, the criteria for a disability rating greater than 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2009). 3. Between June 12, 2004 and May 3, 2007, the criteria for a disability rating greater than 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, DC 9411 (2009). 4. The criteria for entitlement to an effective date prior to June 12, 2004 for the grant of a TDIU have not been met as a matter of law. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2000-2004); 38 C.F.R. § 3.400 (2009). 5. The criteria for an effective date prior to June 12, 2004, for eligibility for DEA under 38 U.S.C. Chapter 35 have not been met. 38 U.S.C.A. § 3501 (West 2002); 38 C.F.R. §§ 3.807, 4.15, 21.3021 (2009). 6. The criteria for the award of special monthly compensation based on the need for regular aid and attendance or due to housebound status have not been not met. 38 U.S.C.A. §§ 1114, 5107 (West 2002 & Supp. 2009), 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, the Department of Veteran's Affairs (VA) has met all statutory and regulatory notice and duty to assist provisions. 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, 3.326(a) (2009). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her representative, if any, of any information and 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). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. With respect to the Veteran's claims for service connection for gout and an increased rating for PTSD, VCAA letters dated in February 2004, June 2004, August 2004, March 2006, August 2006, and May 2008 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2009); 38 C.F.R. § 3.159(b)(1) (2009); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The March 2006, August 2006, and May 2008 letters also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With respect to the other claims noted above, the Board notes that these claims arose from the September 2008 rating decision granting increased ratings for PTSD, a grant of TDIU, and finding of eligibility for DEA. As these claims for an earlier effective date and eligibility for special monthly compensation for aid and attendance or on account of being homebound are considered "downstream" issues, a specific VCAA notice letter addressing requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 with respect to these issues was not required. See VAOPGCPREC 8-2003 (Dec. 22, 2003) (If, in response to notice of its decision on a claim for which VA has already given the 38 U.S.C. § 5103(a) notice, VA receives a notice of disagreement that raises a new issue, 38 U.S.C. § 7105(d) requires VA to take proper action and issue a statement of the case if the disagreement is not resolved, but section 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly raised issue). Moreover, the Federal Circuit has held that 38 U.S.C. § 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate a claim upon receipt of a notice of disagreement with the initial evaluation assigned by a RO for a compensation award. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). In this regard, once a decision has been made awarding service connection, a disability rating, and an effective date, § 5103(a) notice has served its purpose, as the claim has already been substantiated. Sutton v. Nicholson, 20 Vet. App. 419 (2006). In addition, it is clear from the statements of the Veteran and his attorney representative that they understood how to substantiate the claims on appeal. Thus, any error in the content or timing of notice is nonprejudicial. The Board also concludes VA's duty to assist has been satisfied. The Veteran's VA and service treatment records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. Furthermore, the Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. With respect to the Veteran's claim of entitlement to service connection for gout, the Board concludes an examination is not needed. VA has a duty to provide a VA examination when the record lacks evidence to decide the Veteran's claim and there is evidence of: (1) a current disability; (2) an in- service event, injury, or disease; and (3) some indication that the claimed disability may be associated with the established event, injury, or disease. Id.; see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). As will be discussed in greater detail below, the Veteran claims that he currently has gout due to excessive alcohol consumption caused by his service-connected PTSD. To that end, the Board remanded the claim in December 2008 to determine whether there was any connection between the Veteran's service-connected PTSD and excessive alcohol use and, if so, whether the excessive alcohol use caused the Veteran's gout. An April 2009 VA opinion found no relation between excessive alcohol use and the Veteran's PTSD. The Veteran concedes that his symptoms and diagnosis of gout was not until approximately 2000. There is also no credible evidence of in-service joint problems. Under such circumstances, the Board finds that obtaining a further VA examination or opinion is not necessary to decide this appeal. 38 C.F.R. § 3.159. With respect to claims for increased rating, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2009). The RO provided the Veteran appropriate VA psychiatric examinations in November 2000, March 2004, April 2007, July 2007, and April 2008. The VA examination reports are thorough and supported by VA outpatient treatment records. The examinations discussed the clinical findings and the Veteran's reported history as necessary to rate the disability under the applicable rating criteria. The examinations also discussed the impact of the disability on the Veteran's daily living. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disabilities since he was last examined. See 38 C.F.R. § 3.327(a) (2009). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95 (April 7, 1995). Based on the examinations and the fact there is no rule as to how current an examination must be, the Board concludes the examinations in this case are adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1131 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. 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) (2009). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2009). Certain diseases, to include arthritis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. § 1112 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.307, 3.309 (2009). As there is no evidence or claim that the Veteran was diagnosed with arthritis in service or within one year of service, the above provision is not applicable. Any disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. See 38 C.F.R. § 3.310 (2009). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). The Board observes that the provisions of 38 C.F.R. § 3.310 were amended, effective as of October 20, 2006, during the pendency of the instant appeal. See 71 Fed. Reg. 52744- 47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by service-connected one is judged. Although the VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen, it was made clear in the comments to the regulation that the changes were intended to place a burden on the Veteran to establish a pre- aggravation baseline level of disability for the nonservice- connected disability before an award of service connection based on aggravation may be made. This had not been the VA's practice and thus suggests that the recent change amounts to a substantive change in the regulation. For this reason and as the Veteran's claims were pending before the regulatory change was made, the Board will consider the Veteran's claims under the prior version of 38 C.F.R. § 3.310 as it is more favorable to the Veteran. Notwithstanding the above, to establish a right to compensation for a present disability on a direct basis, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board notes that the Veteran is a combat veteran awarded, among other decorations and citations, a Combat Infantryman's Badge for his participation in combat during his service in Vietnam. In Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996), the United States Court of Appeals for the Federal Circuit held that under 38 U.S.C.A. § 1154(b), a combat veteran's assertions of an event during combat are to be presumed if consistent with the time, place and circumstances of such service. However, 38 U.S.C.A. § 1154(b) can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). Section 1154(b) does not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. The evidence must still establish by competent medical evidence tending to show a current disability and a nexus between that disability and those service events. See Gregory v. Brown, 8 Vet. App. 563, 567 (1996); see also Kessel v. West, 13 Vet. App. 9, 17-19 (1999). The Veteran appears to allege that he has gout due to excessive alcohol consumption caused by his service-connected PTSD. Initially, the Board notes that the Veteran's service treatment records are wholly silent as to any complaints, treatment, or diagnoses of gout or other joint disorder. Indeed, the Veteran denied joint problems at the time of his September 1970 separation examination and reported that he was in "perfect health." Moreover, he noted that his grandfather had rheumatism. The Veteran concedes he did not seek treatment for gout or other joint problems during service. After service, the Veteran asserts that he was diagnosed with gout in 2000 at a private treatment facility; however, that diagnosis is not of record. In June 2004, the Veteran underwent a general physical at the VAMC and was diagnosed with gout. In a June 2005 VAMC outpatient follow-up note, the medical provider indicated that his gout was stable. During a mental health assessment in December 2005, the Veteran was questioned about his substance use history. He reported that the medication he was taking for gout conflicted with his alcohol use. A July 2008 treatment record noted that the Veteran currently had gout. The Veteran also sought treatment from several private providers. In April 2003, he was seen for complaints of joint pain, and told the treating professional that he had a history of gout. The examiner diagnosed him with early degenerative joint disease in the hands, obesity and a history of gout. In February 2004, the Veteran underwent a routine physical evaluation, at which time there was no mention of gout. In November 2004, the Veteran presented with complaints of pain in his right arm that began approximately three weeks earlier. The examiner assessed a history of gouty arthritis, but noted that there was no evidence of synovitis, no evidence of chronic tophaceous gout, and no joint deformities. She also said that she had no documentation concerning the severity of his condition, and that there were no findings to suggest a significant disability from gout upon examination. In May 2005, the Veteran was examined for complaints of joint aches and pain. The examiner diagnosed gouty arthritis and obesity, and indicated that a check of his uric acid was needed. The Veteran was seen again in October 2005 with continuing complaints of pain in his hands, feet and knees. During this examination, the Veteran denied any alcohol or drug use. The provider diagnosed him with joint pains without evidence of inflammation on examination, and noted that his uric levels had been normal. He told the Veteran that he could not support his then current claim for Social Security disability benefits based on gout, as he had already advised him that he may have another type of arthritis, such as osteoarthritis, and should be evaluated by a rheumatologist at VA. During an October 2006 visit for pulmonary embolus, the Veteran denied having arthralgia (joint pain), and his past medical history only included gastroesophageal reflux disease, and questionable hypertension. There was no diagnosis of gout. After service, the Veteran was service-connected for PTSD, effective from April 2000. In April 2000, a psychiatric examiner noted that the Veteran reported excessive use of alcohol to help control his PTSD symptoms at night, to include nightmares. In June 2000, the Veteran reported that he attempted to control his PTSD symptoms with alcohol, consuming approximately 20 cans of beer two times per week. The Veteran also reported that he began drinking in the military. In March 2001, the Veteran reported that he had quit drinking because it interfered with his arthritis medication. In October 2003, the Veteran reported a history of alcohol use beginning at age 15, drinking his grandfather's homemade wine, as well as the use of drugs. From that point, the Veteran reported periods of alcohol use and abuse, as well as periods without using alcohol. Based on the foregoing, the Board remanded the claim in December 2008 for an opinion as to whether the Veteran's excessive alcohol use was related to his service-connected PTSD. In compliance with the Board's remand instructions, a VA medical opinion was obtained. The VA psychiatrist, based on a review of the claims file and previous interview with the Veteran, opined that it was less likely than not that the Veteran's excessive alcohol consumption during or after service was caused by his service-connected PTSD. The psychiatrist noted that the Veteran's use of alcohol and other drugs began prior to military service, but that such use increased in service. The psychiatrist also noted that the Veteran did not receive in-service treatment for alcohol dependency. The Veteran clearly has joint problems and as recently as July 2008 these have been attributed to gout. Thus, the Veteran appears to have a current diagnosis of gout. The crucial inquiry, therefore, is whether the Veteran's currently diagnosed gout is related to his service-connected PTSD or any other incident of service. For the reasons and bases set forth below, the Board concludes it is not. The Board finds the April 2009 VA opinion to be credible and probative. It was based on a complete review of the claims file and on the examiner's previous interview of the Veteran. Based on the foregoing, the psychiatrist was able to opine that the Veteran's excessive alcohol use was less likely than not caused by his PTSD, given the Veteran's use of alcohol before service and the absence of any treatment for substance abuse in service. The examiner's conclusion is fully explained and consistent with the evidence of record. Consequently, the Board finds this report to be the most probative evidence of record as to whether the Veteran's excessive alcohol use was caused by or a result of his PTSD. The Board has considered the reports of the Veteran and his two friends that he began experiencing joint pain from service. In that regard, the Board notes that the Veteran and one of his friends have asserted that his excessive alcohol use that began in Vietnam and continued after service caused his gout. Initially, the Board notes that the Veteran and his friends are certainly competent to report physical manifestations of joint pain. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, even when a veteran is asserting continuity of symptomatology after service, he or she is not necessarily competent to attribute a current disability to that symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). In this instance, the Veteran as a lay person has not been shown to be capable of making medical conclusions, especially as to complex medical diagnoses such as a link between his current diagnosis of gout and excessive alcohol use from service that was caused by his PTSD symptoms. Moreover, the Board notes that the Veteran denied joint pain or problems during his September 1970 separation examination. Thus, while the Veteran's and his friends' current assertions of continuity may be of some probative value, they are ultimately outweighed by the Veteran's contemporaneous denials of joint pain and noting his excellent health at separation, as well as his failure to seek treatment for joint pain for multiple decades after service. With respect to the Veteran's and his friends' claim that his gout was caused by his excessive alcohol consumption, which was in turn caused by his service- connected PTSD, the Board finds that they are ultimately outweighed by the conclusions of the VA health care specialist discussed above. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As the Board may not rely on its own unsubstantiated medical conclusions, Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991), it must rely on an informed medical opinion in order to adjudicate a claim. In this case, while there is certainly probative evidence weighing both for and against the claim, the Board finds that the greater weight of the probative evidence is against. While the Board is sympathetic to the Veteran's sincere belief that he incurred gout or other joint disability as a result of excessive alcohol consumption that he and his friends attributes to his PTSD symptomatology, the greater weight of competent medical evidence of record does not support this contention. Therefore, service connection is not warranted on either a direct or secondary basis. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim, and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). Increased Rating Disability ratings are assigned, under a schedule for rating disabilities, based on a comparison of the symptoms found to the criteria in the rating schedule. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2009). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2009). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2009). As the claim on appeal is from a decision that granted service connection and assigned an initial rating, "staged" ratings may be assigned, if warranted by the evidence. Fenderson v. West, 12 Vet. App. 119 (1999). As noted above, the Veteran is currently rated at 50 percent for PTSD prior to June 12, 2004 and at 70 percent for PTSD between June 12, 2004 and May 3, 2007. The Veteran claims the ratings do not accurately depict the severity of his condition during these time periods. The General Rating Formula for Mental Disorders provides, in pertinent part: 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 . . . . . . . . . . . . . . . . . . . . . . . 50 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 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 name . . . . . . . . . . . . . . . . . . . . . . . . . 100 38 C.F.R. § 4.130, DC 9411 (2009). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the DC. Instead, VA must consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. Additionally, a Global Assessment of Functioning (GAF) score is often used by treating examiners to reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996). 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 moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). Prior to June 12, 2004 After a careful review of the record and for the reasons and bases expressed immediately below, the Board finds that the Veteran's demonstrated PTSD symptomatology prior to June 12, 2004 does not warrant an evaluation greater than the currently assigned 50 percent rating. In April 2000 the Veteran initially requested VA treatment for PTSD symptoms, reporting bad dreams, paranoid thoughts, memories, difficulty sleeping, increased irritability, flashbacks, and night sweats. That month, the Veteran also received a psychological evaluation wherein he reported the above symptoms, plus diminished interest in activities, heightened startle response, hypervigilence and avoidance behaviors. At the Veteran's mental health intake assessment in May 2000, he reported trouble sleeping, nightmares, and obsessively checking to ensure doors were locked. In May 2000, at the Veteran's initial treatment with a clinical social worker, he reported nightmares, hypervigilence, startle response, intrusive memories, anger problems, and avoidance behavior to cope. The Veteran was afforded a VA examination in November 2000. At that time, the Veteran reported that he was a good worker, but had trouble getting along with his boss and other coworkers. The Veteran reported avoidance behavior, impulsive behavior, concentration problems, exaggerated startle response. On examination, the Veteran had broad affect, euthymic mood, goal directed thought processes, no bizarre ideas, reported flashbacks and nightmares, no evidence of delusions, and he was alert and oriented to person, time, and place. The examiner diagnosed PTSD and assigned a GAF score of 55 based on moderately severe psychological symptoms and moderate difficulty in social and occupational functioning. The Veteran received continued periodic treatment for his PTSD, reporting continued nightmares and anxiety due to work and social functioning. In October 2003 the Veteran presented after being shot at, which the treatment provider noted had decreased the Veteran's functioning level. The provider noted anger management problems and re-experiencing of traumatic events. Based on evaluation and the Veteran's reported symptomatology, the examiner assigned a GAF score of 55. The Veteran was afforded another VA examination in March 2004. At that time, the Veteran reported working for the Detroit Board of Education for 27 years, but that he was taking college classes to earn a business degree and obtain a different job. The examiner noted the Veteran's ongoing treatment for PTSD with the clinical social worker discussed above who found ongoing problems with nightmares and trouble with anger management. The Veteran reported intrusive memories, nightmares once to twice per week, paranoid feelings, nervousness, but no evidence that he felt the traumatic events recurring or intense feelings with exposure to stimuli reminding him of Vietnam. The Veteran reported avoidance behavior, lack of interest, detachment and isolation from social activities, sleep problems, and hypervigilence. On examination, the Veteran was neatly groomed, cooperative, with euthymic mood, mildly constricted affect, normal speech pattern, without evidence of visual hallucinations, delusions, or thought disorders. The Veteran did report hearing gunshots that others did not, but attributed this to being better attuned to listening for them. He denied panic attacks, suicidal or homicidal ideation, or attempted suicide. The examiner noted obsessive checking behavior, for example the stove or door locks. The Veteran also reported excessive cleaning behavior, but otherwise no inappropriate behavior or impaired judgment. The Veteran's memory was normal. The examiner concluded the Veteran manifested clinically significant distress and moderate impairment in social functioning. The examiner continued the diagnosis of PTSD and assigned a GAF score of 55. The Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. As noted above, the Board concludes that the objective medical evidence and the Veteran's own lay statements regarding his symptomatology both show a degree of disability that more nearly approximates a 50 percent disability rating prior to June 12, 2004, under DC 9411. See 38 C.F.R. § 4.7. As explained in more detail above, the symptoms prior to June 12, 2004 are substantially consistent. For this reason, staged ratings are not applicable. See Fenderson, supra. The Board finds that a rating greater than 50 percent is not appropriate prior to June 12, 2004 because the Veteran did not have occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood or total social and occupational impairment as contemplated by a higher rating. Although the Veteran clearly had a serious disability, he exhibited few of the symptoms noted as applicable for a 70 percent rating. He did not exhibit illogical, obscure or irrelevant speech. He was not in a near-continuous state of panic, depression or disorientation. He did not exhibit impairment in thought processes or communication. He did not exhibit inappropriate behavior, other than certain obsessive compulsive behavior relating to checking doors and the stove and excessive cleaning. His personal hygiene was appropriate. There was no objective evidence of disorientation. He did have some social isolation, but treatment records indicated that he did interact socially as a requirement of his job. For example, in July 2000 the Veteran acted as a supervisor while his boss was away and felt that he would be able to handle the social interaction with his co-workers. Furthermore, the Veteran was periodically involved in relationships with females prior to June 12, 2004. Prior to June 12, 2004, the Veteran consistently was assigned GAF scores of 55 prior to June 12, 2004. This GAF score is consistent with the clinical findings, which show that the Veteran's PTSD is manifested by symptoms such as disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. The clinical evidence establishes that the Veteran did not have total occupational impairment as a result of his PTSD prior to June 12, 2004. In fact, despite his PTSD, the Veteran had worked for over 25 years full time for the Detroit Department of Education. Indeed, the Veteran complained when a new supervisor refused to approve overtime. The Veteran reported that he used all available vacation or sick time, but there is no evidence or allegation that the Veteran otherwise experienced decreased reliability or productivity due to his PTSD symptoms. Thus, while the Veteran's problems may have caused some degree of occupational impairment, the fact that the Veteran remained employed for over 25 years, working at least full time, suggests that his employment was not significantly or severely affected. Although the Veteran may have had some occupational impairment, the Board finds that based on the Veteran's work history he did not have a severe or total occupational impairment prior to June 12, 2004. Moreover, the Board notes that the 50 percent rating assigned herein is a recognition of significant industrial impairment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In general, while there is some evidence of social isolation, there is also evidence the Veteran has a relationship with at least two friends who wrote statements regarding his gout, discussed above, and that have known the Veteran for many years. The Veteran also had a relationship with one or more women prior to June 12, 2004. While the Veteran had a preference for being alone, he appears to have socialized with these individuals to some extent. For example, on multiple occasions the Veteran reported having drinks with friends or going to the bar. Moreover, for some of the appellate period the Veteran attended church and sang in the choir. The Board acknowledges that the Veteran reported a history of being severely hypervigilent and engaging in apparent obsessional behavior, and that such manifestations are among the criteria for a 70 percent rating. However, the overall manifestations and level of impairment demonstrated by the record otherwise appear entirely consistent with a 50 percent rating and no more, prior to June 12, 2004. Consequently, despite the history of severe hypervigilence and apparent obsessional behavior, the Board finds that the preponderance of the evidence is against granting a higher disability rating. In summary, for the reasons and bases set forth above, the Board concludes that a rating higher than 50 percent during any portion of the time period prior to June 12, 2004 is not warranted. See Fenderson, supra. From June 12, 2004 to May 3, 2007 After a careful review of the record and for the reasons and bases expressed immediately below, the Board finds that the Veteran's demonstrated PTSD symptomatology from June 12, 2004 to May 3, 2007 does not warrant an evaluation greater than the currently assigned 70 percent rating. The claims file indicates that the Veteran was separated from his employment on June 12, 2004. In October 2004, a VA Vocational Rehabilitation Panel determined "it is not reasonable to expect you to be able to train for or get a suitable job at this time," based on a narrative report from October 2004. That report noted the Veteran had "fairly severe" emotional problems. The report concluded that the Veteran's PTSD symptoms likely would make it necessary for the Veteran to find a job that would permit him to work primarily alone. Unfortunately, the Veteran's gout and other physical problems made work in the majority of positions allowing for that, for example technical and more physical jobs, difficult or impossible. Due to this combination of emotional and physical problems, the evaluator concluded that the Veteran was not feasible for employment. In January 2005, the Veteran contacted the VA clinical social worker by whom he had previously been treated. At that time, the Veteran reported flashbacks, nightmares, paranoid thoughts, depression/anger, isolation, and insomnia. The Veteran denied suicidal ideation, but was concerned about his ability to control his anger around others. The Veteran noted that he had been laid off or been required to take mandatory retirement. In January 2006, the Veteran was seen at the VA for a regular follow-up visit. At that time, the Veteran noted that he had discontinued therapy because he did not find that it helped. He reported current nightmares, insomnia, and paranoid feelings. The Veteran noted having suicidal thoughts in 1995 after the death of his sister, but none currently. At that time, the Veteran was neatly dressed, guarded and cooperative, with less dysphoric affect, normal speech patterns, serious mood, intact thought processes without delusions or hallucinations, fair but distrustful perception, impulsive judgment, intact memory, and he was alert and fully oriented. The examiner continued the diagnosis of PTSD and assigned a GAF score of 61. In January 2007, the Veteran was seen at the VA for a regular follow-up visit. At that time, the Veteran noted that he had discontinued therapy because he did not find that it helped. He reported current nightmares, insomnia, and paranoid feelings. The Veteran noted having suicidal thoughts in 1995 after the death of his sister, but none currently. At that time, the Veteran was neatly dressed, guarded and cooperative, with dysphoric affect, normal speech patterns, intact thought processes without delusions or hallucinations, fair but distrustful perception, intact memory, and he was alert and fully oriented. The examiner continued the diagnosis of PTSD and assigned a GAF score of 55. In April 2007, the Veteran was afforded a VA examination. The Veteran reported that he had been laid off in 2004 for "behavioral issues", which he thought was unfair and had not since returned to work. The Veteran reported no new significant relationships or social issues since the last VA examination. The examiner noted that the Veteran had significant difficulty trusting or being with other people. On examination, the Veteran had blunted affect, was anxious and irritable, normal speech but short, no hallucinations or delusions, no formal thought disorder, no suicidal plan or intent, evidence of poor judgment in the past, and showed good insight. The examiner diagnosed PTSD and assigned a GAF score of 50, noting that the Veteran's symptoms had worsened since the March 2004 VA examination and that the Veteran had severe impairment in occupational and social functioning. The RO sought a medical opinion in July 2007 from the April 2007 examiner to afford him an opportunity to review of the claims file. The VA psychiatrist noted that the Veteran had marked impairment of social and occupational functioning, with little social interaction. The psychiatrist also opined that there was marked impairment in judgment, thinking and mood. The Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. As noted above, the Board concludes that the objective medical evidence and the Veteran's own lay statements regarding his symptomatology both show a degree of disability that more nearly approximates a 70 percent disability rating from June 12, 2004 to May 3, 2007, under DC 9411. See 38 C.F.R. § 4.7. As explained in more detail above, the symptoms throughout the time period noted are substantially consistent. For this reason, staged ratings are not applicable. See Fenderson, supra. From June 12, 2004 to May 3, 2007, the Veteran's PTSD was manifested by symptoms such as flashbacks, nightmares, paranoid thoughts, poor judgment, depression/anger, isolation, and insomnia. The Veteran also reported occupational and social difficulties; primarily, that he lost his job on June 12, 2004. The Veteran, however, manifested few symptoms associated with a 100 percent rating under the applicable rating criteria. From June 12, 2004 to May 3, 2007, the Veteran manifested few symptoms associated with total social and occupational impairment, such as impaired thought processes or communication, persistent danger of hurting himself or others, delusions or hallucinations, inappropriate behavior, deficient personal hygiene, disorientation or memory loss. More importantly, the Veteran did not have total social and occupational impairment between June 12, 2004 and May 3, 2007, as specifically found by the April 2007 examiner. The Veteran did have severe deficiencies in these areas, but that is contemplated in ratings lower than 100 percent. Since the Veteran has some of the criteria for a 70 percent rating, along with several psychiatric symptoms not listed in the rating schedule such as loss of interest, irritability, etc., see Mauerhan, supra, the Board concludes his overall level of disability more nearly approximates that consistent with a 70 percent rating from June 12, 2004 to May 3, 2007. The Board observes there were potentially contradictory GAF scores during this period, to include a 61 in January 2006, a 55 in January 2007, and a 50 in April 2007. These scores range between manifestations of mild and serious symptomatology. However, given the overall consistent reports of symptomatology consistent with a 70 percent rating during this time period, the Board concludes that a 70 percent rating is appropriate and a higher rating is not warranted. The Board has considered the October 2004 vocational rehabilitation assessment finding the Veteran unemployable. The Board notes, however, this evaluation was based on multiple physical and emotional considerations, both service- connected and nonservice-connected, and not solely on the Veteran's PTSD. In that regard, the Board notes that the evaluator found the Veteran's PTSD symptoms alone did not preclude him from certain employment positions, to include technical and more physically demanding occupations. Thus, the October 2004 assessment did not find the Veteran to have total occupational impairment between June 12, 2004 and May 3, 2007 due to his PTSD symptoms. In summary, for the reasons and bases set forth above, the Board concludes that a rating higher than 70 percent during any portion of the time period from June 12, 2004 to May 3, 2007 is not warranted. See Fenderson, supra. Extraschedular Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See 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. See 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. See 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 Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran'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. 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 disability with the established criteria shows that the rating criteria reasonably describe 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 the Veteran was hospitalized during the appellate time period for his PTSD. Additionally, there is not shown to be evidence of marked interference with employment due to the disabilities prior to May 3, 2007. Prior to June 12, 2004, the Veteran was employed full time for an employer with whom he worked for over 25 years. The evidence suggests that the Veteran worked full time, as well as overtime when available. The Board notes there is conflicting evidence as to the reason for the Veteran's separation on June 12, 2004. The Veteran has alternately reported the separation was due to financial reasons of the employer and for behavioral issues of the Veteran. In either case, the October 2004 vocational assessment found the Veteran unemployable due to a combination of factors, including age, tinnitus, gout, and PTSD symptoms. The evaluator noted that the Veteran's PTSD symptoms did not preclude employment of the type that he had worked all his life, that is technical or more physically demanding positions. Unfortunately, the Veteran's physical problems and his age made work in these positions unlikely. Thus, while the Veteran's PTSD symptoms prevented him from working in positions requiring significant interpersonal interaction, his symptomatology did not prevent him from working in the same or similar type of job that he had done for the previous 27 years. To the extent he had problems with social isolation following his separation from employment on June 12, 2004, the Board finds the 70 percent rating assigned from June 12, 2004 is indicative of a significant degree of industrial incapacity. In short, there is nothing in the record to indicate that the service-connected disabilities on appeal cause 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) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Earlier Effective Date for TDIU A TDIU claim is a claim for increased compensation, and the effective date rules for increased compensation apply to a TDIU claim. Hurd v. West, 13 Vet. App. 449 (2000). The effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. An exception to that rule applies, however, under circumstances where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. In such an instance, the law provides that the effective date of the award "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C.A. § 5110(b)(2); see also 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125 (1997). The Veteran raised a formal claim for a TDIU in September 2005. TDIU was granted in a September 2008 rating decision, effective from June 12, 2004. Initially, the Board notes that the Court has recently held that a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when entitlement to TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits for the underlying disability. Id at 454. The Board notes that the Veteran's claim for PTSD was raised in April 2000 and service connection eventually awarded from that date. Thus, the Board will consider the applicability for TDIU from that point. Following the September 2008 rating decision, the Veteran subsequently submitted a statement in June 2009 in which he expressed disagreement with the effective date assigned for the TDIU. The Veteran subsequently filed a timely substantive appeal. Thus, the claim for an earlier effective date for the grant of a TDIU is properly before the Board as a downstream issue. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). Generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (2000-2004). Total disability ratings are authorized for any disability or combination of disabilities for which the Schedule prescribes a 100 percent disability evaluation, or, with less disability, if certain criteria are met. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2000- 2004). Prior to June 12, 2004, these criteria are not satisfied in the instant case. The Veteran's only service-connected disabilities at that time were PTSD and tinnitus. As discussed in detail above, the Veteran's PTSD disability was evaluated as 50 percent disabling prior to June 12, 2004. The tinnitus disability was and is rated as 10 percent disabling. Thus, the criteria of 38 C.F.R. § 4.16(a) were not met prior to June 12, 2004. The failure to satisfy the criteria of 38 C.F.R. § 4.16(a), however, does not necessarily preclude the assignment of TDIU benefits, in that such benefits can be assigned on an extraschedular basis. See 38 C.F.R. § 3.321. In circumstances such as the instant case, where the Veteran is less than totally disabled under the schedular criteria, it must be found that service-connected disorders, and service-connected disorders alone, prevent him from securing and maintaining substantially gainful employment. The fact that a veteran may currently be unemployed is not, in and of itself, dispositive; the critical factor is the impact of service-connected disorders on a veteran's ability to work. In determining whether a veteran is entitled to individual unemployability, neither his nonservice-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Thus, in deciding the claim, the Board may not favorably consider the effects of the Veteran's nonservice-connected disabilities with respect to their degree of interference with the Veteran's employability. In this case, as discussed above, the Veteran was employed full-time with the Detroit Public Schools system until June 12, 2004. The Veteran contends that he used all available leave time during all or some portion of his more than 25 years of employment with this employer. The Veteran also reported on multiple occasions prior to separation that he was having difficulty with his co-workers. However, the claims file indicates that the Veteran worked overtime when available. The Board acknowledges there is some dispute as to the reasons and nature of the Veteran's separation. The Veteran has stated, alternately, that his separation was based on behavioral problems or for financial reasons of the employer. In either case, the Veteran acknowledges that his separation was classified as retirement and that he remained eligible for and has been receiving his pension. While the Board sympathizes that the Veteran had certain occupational difficulties with co-workers and other aspects of his job prior to June 12, 2004, there is no evidence that his PTSD or other service-connected disabilities caused marked interference with his occupation. In sum, the objective medical evidence simply does not establish that the Veteran was unable to obtain a substantially gainful occupation solely as a result of his service-connected PTSD prior to June 12, 2004. While the Board does not wish to minimize the nature and extent of the Veteran's overall disability, the evidence of record does not support the Veteran's claim that his service-connected PTSD prevented him from engaging in substantially gainful employment during this period, without regard to his age or nonservice-connected disabilities. Therefore, referral for consideration of a TDIU on an extra-schedular basis is not warranted. 38 C.F.R. § 4.16(b). Earlier Effective Date for DEA Essentially, the Veteran contends that he should have an effective date earlier than June 12, 2004, for eligibility for DEA under 38 U.S.C. Chapter 35. For the purposes of DEA under 38 U.S.C. Chapter 35, basic eligibility exists if the Veteran was discharged from service under conditions other than dishonorable and if he has a permanent and total service-connected disability. 38 U.S.C.A. § 3501 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.807, 21.3021 (2009). There are other avenues through which basic eligibility may be granted; however, they involve factors not applicable here, e.g., the death of the Veteran or if the Veteran is currently on active duty. Id. After reviewing the record and as discussed above, the Board finds that the Veteran did not meet the criteria for a permanent and total disability rating for compensation purposes prior to June 12, 2004. Therefore, an effective date for the assignment of an effective date prior to June 12, 2004, is not warranted. Since eligibility for DEA under 38 U.S.C. Chapter 35 is predicated on a finding of permanent total disability in this case, the effective date of such eligibility cannot precede June 12, 2004. In this case, the RO has found the Veteran to be permanently and totally disabled, as explained by the RO in the September 2008 rating decision. This determination was made as a direct consequence of the award of a 70 percent schedular rating for PTSD, effective June 12, 2004. As the claims for an earlier effective date for the 70 percent rating for PTSD and for TDIU were denied herein, the claim for an earlier effective date for the award of DEA must also be denied. Eligibility for DEA under 38 U.S.C. Chapter 35 is, effectively, derived from and cannot precede that date. The law is dispositive of the issue; and, therefore, the appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Entitlement to Special Monthly Compensation The Veteran contends that he is eligible for special monthly compensation (SMC). SMC is payable at a specified rate if the Veteran, as the result of service-connected disability, is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C.A. § 1114(l) (West 2002); 38 C.F.R. § 3.350(b) (2009). The following will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. "Bedridden" will be a proper basis for the determination. 38 C.F.R. § 3.352(a) (2009). It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. The particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there is a constant need. 38 C.F.R. § 3.352(a); see also Turco v. Brown, 9 Vet. App. 222, 224 (1996) (noting that at least one factor listed in § 3.352(a) must be present for a grant of special monthly pension based on need for aid and attendance). For the purposes of 38 C.F.R. § 3.352(a), "bedridden" will be a proper basis for the determination of whether the Veteran is in need of regular aid and attendance of another person. "Bedridden" will be that condition which, through its essential character, actually requires that the Veteran remain in bed. The fact that the Veteran has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352(a). Under 38 U.S.C.A. § 1114(s), special monthly compensation is payable if the Veteran has a single service-connected disability rated as 100 percent and, (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. The second requirement is met when the Veteran is substantially confined as a direct result of service- connected disabilities to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). The Board initially notes that the Veteran does not meet the criteria for special monthly compensation at the housebound rate, based on one service-connected disability rated as 100 percent disabling and a separate disability rated at 60 percent or higher. The Board notes that service connection is currently in effect for PTSD, rated as 100 percent disabling, effective May 3, 2007; and tinnitus, rated as 10 percent disabling. As discussed above, a TDIU is in effect, effective June 12, 2004, due to impairment caused by his PTSD disability. In addition, the evidence of record does not demonstrate that the Veteran is unable to engage in activities outside of his home. Indeed, the private medical records indicate that the Veteran is able to attend treatment sessions at the VAMC and maintenance activities such as shopping for food. Additionally, the Board notes that evidence of record does not show that the Veteran's service-connected disabilities have caused the anatomical loss or loss of use of both feet or one hand and one foot, and he is not blind in both eyes. Consequently, the Veteran can only establish entitlement to SMC under 38 U.S.C.A. § 1114(l) by showing his service- connected disabilities cause him to be permanently bedridden or so helpless as to be in need of regular aid and attendance under the criteria of 38 C.F.R. § 3.352(a) set forth above. In this regard, the medical evidence does not demonstrate that the Veteran requires regular aid and attendance due to his service-connected disabilities. The record indicates that in April 2008, at the time of the last VA psychiatric examination, the Veteran was able to complete activities of daily living independently and that he was groomed appropriately at the examination. Moreover, the Veteran reported that he spent his time exercising, practicing with his weapons, and practicing martial arts. Overall, the Veteran reported moderate difficulty in getting the housework done that was necessary. To that end, the Veteran stated that he had severe difficulty with concentration, remembering, analyzing, and finding solutions to problems in day-to-day life. The claims file does not include any medical record suggesting a more severe level of impairment with respect to the performance of activities of daily living or otherwise suggesting that the Veteran is bedridden or so helpless that he requires regular aid and attendance. On further review of the record, the Board concludes that the evidence does not show that the Veteran is permanently bedridden, or so helpless as to be in need of regular aid and attendance due to service-connected disability. Indeed, as indicated above, the Veteran can perform all activities of daily living, albeit with difficulty. In sum, the competent evidence of record does not indicate that the Veteran's service-connected disabilities prevent him from performing any activities of daily living. The Veteran has not provided or identified any evidence to the contrary. See 38 U.S.C.A. § 5107(a). Based on the foregoing, the Board finds that the claim for SMC based on aid and attendance or housebound status must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for gout is denied. Entitlement to an initial rating greater than 50 percent prior to June 12, 2004 and greater than 70 percent from June 12, 2004 to May 3, 2007 for posttraumatic stress disorder (PTSD) is denied. Entitlement to an effective date earlier than June 12, 2004 for the grant of total disability based on individual unemployability (TDIU) is denied. Entitlement to an effective date earlier than June 12, 2004 for the grant of eligibility to Dependents' Educational Assistance (DEA) is denied. Entitlement to special monthly compensation by reason of being in need of the regular aid and attendance or on account of being housebound is denied. ____________________________________________ J. K. BARONE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs