Citation Nr: 1122923 Decision Date: 06/15/11 Archive Date: 06/28/11 DOCKET NO. 08-21 609 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder. 2. Entitlement to a disability rating in excess of 30 percent for gunshot wound residuals of the left hand. 3. Entitlement to a total disability rating based on individual unemployability. REPRESENTATION Veteran represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1965 to May 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In 2006, the RO granted entitlement to increased, 30 percent, disability ratings for PTSD and the left hand gunshot residuals. During the pendency of this appeal, the RO issued an April 2011 rating decision, granting entitlement to a 50 percent disability rating for PTSD. However, as the Veteran, through his authorized representative, subsequently requested entitlement to an evaluation in excess of 50 percent, the issue of entitlement to an increased evaluation for PTSD remains on appeal. FINDINGS OF FACT 1. The evidence does not establish that, prior to January 19, 2010, the Veteran's PTSD, alone, was more severe than as characterized by 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 2. The evidence establishes that the Veteran's PTSD, since January 19, 2010, approximates 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 that is 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 work-like setting); and an inability to establish and maintain effective relationships. 3. The record does not reflect that the Veteran has, during the appellate period, experienced hospitalization for PTSD or that this disability presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. 4. The Veteran's service-connected residuals of gunshot wounds to the left hand are not manifested by complete paralysis of the ulnar nerve or by loss of deep fascia or an inability to keep up with work requirements. 5. The record does not reflect that the Veteran has experienced hospitalization or that his left hand disability presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. 6. With resolution of the benefit of the doubt in the Veteran's favor, the Veteran's service-connected disabilities, without regard to age or other disabilities, preclude him from obtaining and retaining all forms of substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent rating for PTSD, prior to January 19, 2010, are not met. 38 U.S.C.A. § 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.126, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a 70 percent disability rating for PTSD are approximated from January 19, 2010. 38 U.S.C.A. § 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.126, 4.130, Diagnostic Code 9411 (2010). 3. The Veteran has not presented evidence such that referral for the assignment of an extraschedular rating, for PTSD, pursuant to 38 C.F.R. § 3.321(b)(1), is warranted. 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 3.326 (2010). 4. The criteria for a disability rating in excess of 30 percent for the Veteran's residuals of gunshot wound to the left hand are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8516, 8615 (2010). 5. The Veteran has not presented evidence such that referral for the assignment of an extraschedular rating, for his left hand disability, pursuant to 38 C.F.R. § 3.321(b)(1), is warranted. 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 3.326 (2010). 6. The criteria for an award of TDIU are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16(a)(b) (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board will discuss the relevant law which it is required to apply. This includes statutes published in Title 38, United States Code ("38 U.S.C.A."); regulations published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (Implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (The Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). Duties to Assist and Notify The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice 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; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1). An August 2006 VCAA letter explained the evidence necessary to substantiate the claim for an increased rating and informed the Veteran of his and VA's respective duties for obtaining evidence. The letter also explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-491 (2006). This letter was provided to the Veteran prior to the initial adjudication of his claim, pursuant to Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was subsequently, in an August 2008 letter, advised of the specific rating criteria of his disabilities, in compliance with Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). However, the Court held in Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009) that VCAA notice in a claim for increased rating need not be "veteran specific" or include reference to impact on daily life or rating criteria. As such, the Veteran received legally sufficient notice prior to the initial adjudication. Regardless, although the August 2008 letter was sent after the initial adjudication (and thus would represent a timing error per see Pelegrini, 18 Vet. App. 112), the RO readjudicated the claim in an April 2011 statement of the case (SOC) and timing errors can be effectively "cured" by providing the necessary additional notice and readjudicating the claim. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). As such, the Board finds that the duty to notify has been met. VA has a duty to assist veterans in obtaining evidence necessary to substantiate their claims. The claims file contains service treatment records, reports of post-service medical treatment, and reports of VA examinations (November 2006 and January 2010). With respect to the VA examinations, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The 2006 VA examination reports reflect review of the claims file, examination of the Veteran, and description and evaluation of the left hand disability and PTSD. Although the 2010 VA examination reports do not reflect review of the claims file, they do reflect interview with and examination of the Veteran. As the present level of disability is of primary concern (per Francisco v. Brown, 7 Vet. App. 55, 58 (1994)) and the 2010 examination reports reflect thorough and contemporaneous evaluation of the level of disability of the left hand disability and PTSD, the Board finds the examination findings sufficient for proper application of the relevant rating criteria and adequate for the purpose of adjudication. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the particular claims on appeal. He has been given ample opportunity to present evidence and argument in support of his claims. As such, and pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. The Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2010). Increased Ratings Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history. 38 C.F.R. §§ 4.2, 4.41. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The following discussion addresses the Veteran's levels of disability from the time the increased rating claim was filed in July 2006. Francisco, 7 Vet. App. 55; Hart, 21 Vet. App. 505. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his or her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence, and on what the evidence shows or fails to show with respect to the appeal. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). Ratings shall be based, as far as practicable, upon the average impairments of earning capacity; however, the Secretary shall, from time to time, readjust this schedule of ratings in accordance with experience. To accord justice in an exceptional case in which the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is 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 as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). PTSD The Veteran seeks entitlement to a disability rating in excess of 50 percent for his service connected psychiatric disability. He submitted a claim for an increased rating in July 2006 and, in a December 2006 rating decision, the RO granted a 30 percent rating effective the date of his claim. The Veteran timely appealed that decision, noting disagreement with the level of disability that was assigned. In April 2011, the RO granted a 50 percent disability rating effective the date of his claim; the Veteran indicated in later April 2011 that a 50 percent disability rating did not satisfy his appeal. For the reasons and bases discussed below, the Board finds that the 50 percent rating is appropriate for his disability prior to January 2010, but a 70 percent rating is appropriate from the date of a VA-provided mental disorders examination - January 19, 2010. The Veteran's psychiatric disorder has been evaluated under the general rating formula for mental disorders (38 C.F.R. § 4.130): A 30 percent rating is warranted where the disorder is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, and mild memory loss. A 50 percent rating is warranted where the disorder is manifested by occupational and social impairment with reduced reliability and productivity due to particular symptoms such 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where the disorder is manifested by 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 that is 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 work-like setting); and an inability to establish and maintain effective relationships. A 100 percent rating is indicative of 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 of names of close relatives, own occupation or own name. The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are 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 when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are 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). GAF scores ranging between 31 and 40 are assigned when there is 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). Symptoms listed in VA's general rating formula for mental disorders 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). The Veteran was afforded a VA examination in November 2006. The report from that examination reflects that the Veteran stated he did not have difficulty performing activities of daily living, but reported strained relationships with his children; he attributed the strain to the children's drug use. The Veteran denied current treatment for PTSD. He stated that he was not currently employed due to physical problems, but, when he was employed, he struggled with anxiety. The Veteran reported an increase in suspiciousness of others, crowd avoidance, waking at night due to nightmares, increased depression, lack of energy, and hopelessness. The examiner observed that he was alert and oriented with a flat affect and logical thought processes. The examiner assigned a GAF score of 55 and assessed his PTSD symptomatology as resulting in moderate impairment in social functioning, specifically communication and interaction with others, and moderate interference with his employment functioning. The examiner opined that the Veteran's "prognosis [wa]s poor due to his unwillingness to stop drinking and his lack of engagement in PTSD treatment." The Veteran was afforded another mental disorders examination on January 19, 2010. He reported being unemployed and living with his second wife. He also described various memories from his active duty and stated feeling 'haunted' by some memories. The Veteran reported experiencing sleep problems ever since his active duty service, not doing much during the day, and feeling irritable and angry around people with whom he has little in common. The examination report indicates the occurrence of nightmares every other evening, feelings of sadness when thinking about his active duty, and avoidance of conflicts with his wife leading to a poor marital relationship. The examiner noted that the Veteran was not receiving any treatment for PTSD and did not engage in social functions. The examination report reflects that the Veteran was appropriately oriented and his behavior was appropriate. However, his hygiene was described as marginal due to stained finger nails and poor dental hygiene. Affect and mood were described as depressed (as often as a few times a week, with each episode lasting for one day) with anxiety over confrontation. There were no panic attacks and communication, speech, memory, judgment, and thought process were noted as normal. No delusions or hallucinations were noted. Although the examiner observed impaired attention/focus, that impairment was attributed to tinnitus. The examiner noted passive thoughts of death, but no homicidal ideation. The 2010 examiner assigned a GAF of 55. The examination report reflects that the Veteran demonstrates avoidance of stimuli associated with trauma, feels detached/estranged from others, has a restricted range of affect, and experiences persistent symptoms of increased arousal such as hypervigilance, irritability, difficulty concentrating, and difficulty falling or staying asleep. The examiner noted that PTSD symptoms cause social and occupational impairment and stated that the Veteran had stopped going to bars or other places where fights might break out since he may become angry and involve himself in a fight; he reported that such scenarios had ended poorly for him in the past. The Veteran was described as "unable" to establish and maintain effective work/school and social relationships - an assessment which is supported by data in that portion of the report entitled "Mental Status Examination," which details the Veteran avoiding opportunities for confrontation and social withdrawal. The examination report concludes with the examiner's observation that the prognosis for the mental disorder is poor due to the longstanding nature of his PTSD. As noted above, the Veteran's PTSD is rated as 50 percent disabling. A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to particular symptoms such 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A higher, 70 percent, rating is not warranted unless there is 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 that is 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 work-like setting); and an inability to establish and maintain effective relationships. Here the Veteran has been observed to experience occupational and social impairment due to PTSD. That impairment is due to symptoms such as depressed mood, anxiety, suspiciousness, and chronic sleep impairment, which are encompassed by the 30 percent disability rating. Both examiners have observed flattened affect and impairment of motivation and mood, which are encompassed by the 50 percent disability rating. However, the 2010 examiner observed the following symptoms which were not noted by the 2006 examiner: marginal hygiene; passive thoughts of death; irritability with possibility of violence; and an inability to establish and maintain effective work/school relationships. Although GAF scores are just one of the medical findings employed in a rating determination and the score assigned does not determine the disability rating VA assigns (see Massey v. Brown, 7 Vet. App. 204, 207 (1994)), the Board observes that the Veteran was assigned a GAF score of 55 in both 2006 and 2010; scores ranging between 51 and 60 are assigned when there are moderate symptoms. The evidence of record reflects that the Veteran's PTSD, prior to January 2010, was manifested by symptoms consistent with 30 percent and 50 percent disability ratings such as anxiety, sleep problems, increased suspiciousness of others, crowd avoidance, nightmares, depression, and flat affect; there was no evidence of panic attacks or memory impairment. However, as noted above, in January 2010, VA examination revealed evidence of additional impairment due to PTSD. Pursuant to 38 C.F.R. § 4.7, a higher disability evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. As the Veteran's PTSD, in 2010, resulted in manifestation of additional symptoms such as marginal hygiene, thoughts of death, unprovoked irritability, and an inability to establish and maintain effective work/school relationships, the Board finds that the current, from January 2010, disability picture more nearly approximates the criteria for a 70 percent disability rating. Gilbert, 1 Vet. App. 49. A 70 percent rating will therefore be granted effective the date of the VA-sponsored examination, January 19, 2010. As there is no evidence of total occupational and social impairment with gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, or persistent danger of hurting self or others, disorientation to time or place, or memory loss of names, a 100 percent disability rating is not appropriate. The 2010 examiner did observe intermittent inability to perform activities of daily living, but noted that inability did not extend to self -care (the extent of such an inability contemplated by a 100 percent disability rating includes lack of self-care). The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The Court has held that the threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). The record reflects that the Veteran has not required frequent hospitalizations for his PTSD symptoms. Although the record reflects that his PTSD impacts his occupational functioning, that impact is contemplated by his schedular disability evaluations. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability."). Specifically, a 50 percent disability rating contemplates difficulty in establishing and maintaining effective work and social relationships (as noted by the 2006 examiner) and a 70 percent disability rating contemplates an inability to establish and maintain such relationship (as noted by the 2010 examiner). As described above, the manifestations of the Veteran's PTSD are contemplated by the schedular criteria; no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. Left Hand In evaluating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability so that actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Generally, regarding the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing are related considerations. 38 C.F.R. § 4.45. The criteria for evaluating disabilities involving the fingers were revised in August 2002. The criteria in effect since August 26, 2002 provide for limitation of motion of a finger or multiple fingers. 38 C.F.R. § 4.71a, Codes 5228, 5229 (2010). When two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is not otherwise specified in the Rating Schedule, the evaluation level assigned will be that which best represents the overall disability (i.e., limitation of motion), assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level. 38 C.F.R. § 4.71a, Note (2) between Code 5215 and Code 5216 (2010). "Ankylosis" means immobility and consolidation of a joint due to disease, injury, or surgical procedure. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 94 (31st ed. 2007). As to limitation of motion of an index or long finger, a noncompensable evaluation is warranted when there is a gap of less than one inch (2.5 centimeters) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. 38 C.F.R. § 4.71a, Code 5229 (2010). An evaluation of 10 percent requires limitation of motion of the index finger with a gap of one inch (2.5 centimeters) or more between the fingertip and the proximal transverse crease of the palm of the hand, with the finger flexed to the extent possible or with extension of the index finger limited by more than 30 degrees. Id. Code 5230 provides for a noncompensable evaluation for any limitation of motion of the ring (third) finger. A compensable evaluation is not available. 38 C.F.R. § 4.71a. An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a) (2010). A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each muscles damaged. 38 C.F.R. § 4.56(b) (2010). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c) (2010). Evaluation of muscle injuries as slight, moderate, moderately severe, or severe is based on the type of injury, the history and complaints of the injury, and objective findings. 38 C.F.R. § 4.56(d). The Court, citing Robertson v. Brown, 5 Vet. App. 70 (1993), has held that 38 C.F.R. § 4.56(d) is essentially a totality-of-the-circumstances test and that no single factor is per se controlling. Tropf v. Nicholson, 20 Vet. App. 317 (2006). A slight disability of muscles is described as a simple wound of muscle without debridement or infection. The service department records would demonstrate a superficial wound with brief treatment and return to duty. Healing would be shown as having been with good functional results. No cardinal signs or symptoms of muscle disability would be shown and the scar would be minimal with no evidence of fascial defect, atrophy, or impaired tonus. There would be no impairment of function or metallic fragments retained in muscle tissue. Id. A moderate disability of the muscles may result from through and through or deep penetrating wounds of relatively short track by a single bullet or small shell or shrapnel fragment. The absence of the explosive effect of a high velocity missile and of residuals of debridement or of prolonged infection also reflects moderate injury. The history of the disability should be considered, including service department records or other sufficient evidence of hospitalization in service for treatment of the wound. Consistent complaints on record from the first examination forward of one or more of the cardinal symptoms of muscle wounds, particularly fatigue and fatigue-pain after moderate use, and an effect on the particular functions controlled by the injured muscles should be noted. Evidence of moderate disability includes entrance and (if present) exit scars which are linear or relatively small and so situated as to indicate relatively short track of missile through muscle tissue, signs of moderate loss of deep fascia or muscle substance or impairment of muscle tonus, and of definite weakness or failure in comparative tests. Id. A moderately severe disability of the muscles is characterized by evidence of a through and through or deep penetrating wound by a high velocity missile of small size or a large missile of low velocity, with debridement or with prolonged infection, or with sloughing of soft parts, or intermuscular cicatrization. Service department records or other sufficient evidence showing hospitalization for a prolonged period in service for treatment of a wound of severe grade should be considered. Records in the file of consistent complaints of cardinal symptoms of muscle wounds should also be noted. Evidence of unemployability due to an inability to keep up with work requirements may be considered. Objective findings should include relatively large entrance and (if present) exit scars so situated as to indicate the track of a missile through important muscle groups. Indications on palpation of moderate loss of deep fascia, or moderate loss of muscle substance or moderate loss of normal firm resistance of muscles compared with the sound side may be considered. Tests of strength and endurance of the muscle groups involved may also give evidence of marked or moderately severe loss. Id. A severe disability of the muscles is characterized by evidence of through and through or deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or explosive effect of a high velocity missile, or shattering bone fracture with extensive debridement or prolonged infection and sloughing of soft parts, intermuscular binding and cicatrization. Service department records or other sufficient evidence showing hospitalization for a prolonged period in service for treatment of a wound of severe grade should be considered. Records in the file of consistent complaints of cardinal symptoms of muscle wounds should also be noted. Evidence of unemployability due to an inability to keep up with work requirements may be considered. Id. Objective evidence of severe disability includes extensive ragged, depressed, and adherent scars of skin so situated as to indicate wide damage to muscle groups in the track of a missile. Palpation shows moderate or extensive loss of deep fascia or of muscle substance or soft or flabby muscles in wound area. Muscles do not swell and harden normally in contraction. Tests of strength or endurance compared with the sound side or of coordinated movements show positive evidence of severe impairment of function. Id. 38 C.F.R. § 4.73, Code 5309, provides the rating criteria for evaluation of injuries of Muscle Group IX. Muscle Group IX involves the intrinsic muscles of the hand, including the thenar eminence, the short flexor, opponens, abductor, and adductor of the thumb, hypothenar eminence, the short flexor, opponens, and abductor of the little finger, 4 lumbricales, and 4 dorsal and 3 palmar interossei. Muscle Group IX functions to supplement the strong grasping movements of the forearm muscles with delicate manipulative movements. 38 C.F.R. § 4.73, Diagnostic Code 5309. Because the hand is so compact a structure, isolated muscle injuries are rare, and these injuries are rated based on limitation of motion, with a minimum rating of 10 percent. 38 C.F.R. § 4.73, Diagnostic Code 5309. Under this diagnostic code, a noncompensable evaluation is warranted if impairment of this muscle group is slight; a 10 percent rating is warranted if impairment of this muscle group is moderate; a 20 percent rating is warranted if impairment of this muscle group is moderately severe; and a 30 percent rating is warranted if it is severe to the dominant side. The evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2010). A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of section 4.14. However, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). The Court has emphasized that evaluation of musculoskeletal disabilities also includes consideration of functional loss due to pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination, and of impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2010); DeLuca v. Brown, 8 Vet. App. 202 (1995). After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against a disability rating in excess of 30 percent for the Veteran's left hand disability. The Veteran's left hand disability currently is evaluated, and assigned a 30 percent disability rating, pursuant to the criteria found at 38 C.F.R. § 4.124a, Diagnostic Code 8516. Under this Code, mild incomplete paralysis of either extremity warrants a 10 percent rating. Moderate incomplete paralysis warrants a rating of 20 percent for the minor extremity, and a 30 percent rating for the major extremity. Severe incomplete paralysis warrants a 30 percent rating for the minor extremity, and a 40 percent rating for the major extremity. A maximum evaluation of 50 percent for the minor extremity and 60 percent for the major extremity for complete paralysis of the ulnar nerve of the major upper extremity, which is defined as being manifested by the "griffin claw" deformity due to flexor contraction of the ring and little fingers, very marked atrophy in the dorsal interspace and thenar and hypothenar eminences; loss of extension of the ring and little fingers, inability to spread the fingers (or reverse), inability to adduct the thumb; and weakened flexion of the wrist. As the Veteran's left hand is his minor extremity, his current 30 percent disability rating represents severe incomplete paralysis. A higher rating is not applicable unless there is complete paralysis. Service treatment records reveal that the Veteran was shot in the hand in 1969 while on leave during active duty service; the bullet entered and exited his hand. Medical notes show that five (5) weeks after the gun shot, his hand was "intact," but he experienced hypersensitivity, ulnar nerve distribution, and flexor stiffness in the fourth and fifth digits. Upon discharge from service, the Veteran reported on a self report of medical history that his left thumb was still numb and "fe[lt] cold all the time." His discharge medical examination states that his left hand is "ok now except numbness of thumb." Upon examination in November 2006, the Veteran's left hand disability was manifested by minor muscle damage and interference with movements of the fingers and wrist. The examiner noted that metallic fragments remain in the left hand, but there is no evidence of bony deformity. The examination report reflects that the Veteran reported a worsening of his symptoms including daily hand cramping, difficulty holding on to smaller objects, numbing of the hand if it remains in one position, and muscle atrophy over the dorsal hand between the left thumb and index finger. The 2006 examiner observed a well-healed entrance wound just above the wrist between the thenar and hypothenar eminences and an exit wound through the medial aspect of the lateral palm. There was a moderate degree of hypothenar and thenar eminence wasting in the left hand with moderate first dorsal interossei wasting on the left compared to the right. Grip strength on the left was described as 20 to 30 percent reduced on the left as compared to the right and there was moderately severe weakness of the left interossei muscles causing at least 70 percent reduced ability to abduct the fingers. There was weakness of the flexor carpi ulnaris and radialis on the left as well as moderately severe weakness of the left adductor pollicis and opponens pollicis muscles. Sensation to pin prick and light touch were noted as decreased by 50 to 75 percent on the left as compared to the right. The examiner observed visible wasting of left hand muscles and weakness of wrist and finger movements; paresthesias and sensory deficits were observed to encompass areas additional to the ulnar nerve including the median nerve with the thumb and index fingers. EMG study showed mild left ulnar sensory motor neuropathy at the elbow with slow conduction across the elbow and moderate left distal ulnar neuropathy. Another VA examination was provided in January 2010. The examiner noted that there was no paralysis of the affected parts, but the Veteran reported constant tingling, numbness, abnormal sensation, pain, anesthesia, and weakness. The report reflects a linear scar measuring one (1) centimeter by 1 centimeter on the left lateral wrist. The scar was not painful, there were no signs of skin breakdown, no disfigurement, and no resulting limitation of motion or function. On the palmar surface there was a linear 0.5 centimeter by 0.5 centimeter scar which also was not painful, disfiguring, or limiting in terms of motion or function. The 2010 examiner stated that the gunshot injury residuals affected muscle group IX and noted left thenar muscle atrophy without loss of deep fascia. There was evidence of muscle wound at the left palm in an area measuring 0.5 by 0.5 centimeters. Scars were noted to not adhere to the underlying structures and there was no intramuscular scarring or adhesion to the bone. Left grip strength was described as three (3) out of five (5), but there were no signs of lowered endurance or impaired coordination. The examiner noted that the muscle injury did not affect the function of the particular body part it controls, but did involve damage to the left radial nerve. The left hand and wrist did not show any evidence of subluxation, ankylosis, edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, but there was tenderness. Right and left wrist range of motion were the same and the examiner noted that neither wrist function was additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination. During the 2010 examination, manual dexterity was measured and the examiner noted that the left fingertips could approximate the transverse crease of the palm. The measurement between the tip of the left thumb and the tip of each finger was zero centimeters. Upon x-ray, gunshot wound fragments were shown to remain in the soft tissue over the dorsum of the wrist. The 2010 examiner diagnosed peripheral nerve disease in the left hand due to the gunshot wound trauma and stated that there was moderate effect on the Veteran's occupation and daily activity. The examiner clarified that the Veteran never had hypothenar atrophy, only thenar atrophy and stated that the evaluation of the left wrist was normal. The Board notes that the Veteran has never been observed to have ankylosis of any of the affected left hand digits. A moderate disability requires consistent complaints on record from the first examination forward of one or more of the cardinal symptoms of muscle wounds, particularly fatigue and fatigue-pain after moderate use, and an effect on the particular functions controlled by the injured muscles should be noted. Evidence of moderate disability includes entrance and (if present) exit scars which are linear or relatively small and so situated as to indicate relatively short track of missile through muscle tissue, signs of moderate loss of deep fascia or muscle substance or impairment of muscle tonus, and of definite weakness or failure in comparative tests. In the present case, the record shows consistent complaints of numbness and there is evidence of entrance and exit scars. A moderately severe disability of the muscles is characterized by evidence of a through and through or deep penetrating wound by a high velocity missile of small size or a large missile of low velocity, with debridement or with prolonged infection, or with sloughing of soft parts, or intermuscular cicatrization. Service department records or other sufficient evidence showing hospitalization for a prolonged period in service for treatment of a wound of severe grade should be considered. Records in the file of consistent complaints of cardinal symptoms of muscle wounds should also be noted. Evidence of unemployability due to an inability to keep up with work requirements may be considered. Objective findings should include relatively large entrance and (if present) exit scars so situated as to indicate the track of a missile through important muscle groups. Indications on palpation of moderate loss of deep fascia, or moderate loss of muscle substance or moderate loss of normal firm resistance of muscles compared with the sound side may be considered. Tests of strength and endurance of the muscle groups involved may also give evidence of marked or moderately severe loss. Id. Here there is no evidence of prolonged infection, sloughing of soft parts, or intramuscular cicatrization. Further there is no evidence that the gunshot residuals rendered the Veteran unable to keep up with work requirements and the 2010 examiner noted no loss of deep fascia. As such, the Veteran's symptoms do not approximate the criteria for a moderately-severe disability rating of a muscle group disability under Diagnostic Code 5309. Under that Code, a 20 percent rating is warranted if impairment of this muscle group is moderately severe; a 30 percent rating is not warranted unless there is severe impairment to the dominant side. However, the assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Here, the Veteran's gunshot residuals also result in ulnar nerve disability. For the Veteran's ulnar nerve symptoms to warrant a higher disability rating, there must be evidence of symptoms such as complete paralysis, marked atrophy, loss of finger extension and spreading, an inability to adduct the thumb, and weakness of wrist flexion. No examiner has observed complete paralysis of the Veteran's left hand. Although the 2006 examiner diagnosed muscle atrophy over the dorsal hand between the left thumb and index finger and the 2010 examiner diagnosed thenar atrophy, no examiner has described the atrophy as "marked." The 2006 examiner noted some wrist weakness, but neither examiner observed loss of finger extension/ spreading or an inability to adduct the thumb. As such, the Board finds that the Veteran is more than adequately compensated for his level of disability by the currently assigned 30 percent disability rating since there is no evidence of paralysis of the affected parts and a 30 percent rating is warranted under Code 8516 when there is incomplete, severe paralysis of the non-dominant hand. The Board also has considered whether evaluation of the Veteran's disability under any other Diagnostic Code would avail him of a higher rating. As he has never been diagnosed with ankylosis, favorable or unfavorable, of any digit, Codes 5216 through 5227 are not applicable. As noted above, Codes 5229 and 5230 apply to limitation of motion of individual digits: the index or long finger, and ring or little finger, respectively. However, no compensable limitation of finger motion has been noted and, regardless, the highest rating assignable under Code 5230 is a non-compensable rating and the highest rating assignable under Code 5229 is 10 percent so application of these Codes would not avail the Veteran of any higher disability rating. The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). See Barringer v. Peake, 22 Vet. App. 242 (2008). However, the record reflects that the Veteran has not required frequent hospitalization for the disability, and, as discussed above, the manifestations of the disability are not in excess of those contemplated by the assigned rating. Further, although the Veteran experiences occupational impairment, there is no indication in the record that the average industrial impairment from the disability would be in excess of that contemplated by the assigned ratings. Specifically, examiners have noted that the left hand disability causes moderate disability and the Veteran has not contended that his left hand disability markedly interferes with employment. The Court has held that, "if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required." Thun v. Peake, 22 Vet. App. 111, 115 (2008). Therefore, the Board has concluded that referral of this case for extra-schedular consideration is not in order. Total disability rating based on individual unemployability (TDIU) TDIU is an element of all appeals of an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU is granted where a Veteran's service connected disabilities are rated less than total, but prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2010). Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2001) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Here, the Veteran has claimed entitlement to increased ratings for his service-connected disabilities and has informed VA examiners that he is unable to work. As such, under Roberson, an informal claim for TDIU has been raised. In order to establish service connection for a total rating based upon individual unemployability due to service-connected disability (TDIU), there must be an impairment so severe that it is impossible to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Neither non-service-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. VA regulations establish objective and subjective standards for an award of total rating based on unemployability. When the Veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned provided that if there is only one service-connected disability, this disability shall be rated at 60 percent or more. When there are two or more disabilities, at least one disability must be ratable at 40 percent or more, and any additional disabilities must result in a combined rating of 70 percent or more, and the disabled person must be unable to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(a). A total disability rating may also be assigned on an extra-schedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). As a result of this decision, the Veteran's service connected mental disability shall be assigned a 70 percent disability rating, effective January 19, 2010. He is also service-connected for the residuals of a gunshot wound to the left hand rated 30 percent disabling, bilateral tinnitus rated 10 percent disabling, and hearing loss that is non-compensably rated. His combined disability rating as a result of this decision will be 80 percent. Thus, he meets the schedular criteria for consideration of unemployability under 38 C.F.R. § 4.16(a). As such, the Board must determine whether the Veteran is unemployable by reason of his service-connected disabilities. The record reflects that the Veteran was not working at the time of the 2006 or 2010 VA examinations. He informed the 2006 VA examiner that he had not worked for several weeks due to physical problems, but, when working, struggled with anxiety. The 2010 mental disorders examiner observed that the Veteran was incapable of establishing and maintaining effective work relationships and that his service-connected tinnitus further interfered with his concentration and focus. The 2010 orthopedic examiner noted that the Veteran's left hand disability has a moderate effect on his employment. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. However, under the "benefit-of-the-doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). The mandate to accord the benefit of the doubt is triggered when the evidence has reached such a stage of balance. In this matter, the Board is of the opinion that this point has been attained. Because a state of relative equipoise has been reached in this case, the benefit of the doubt rule will therefore be applied. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown, 5 Vet. App. 413, 421 (1993). While no medical professional has stated that the Veteran is unemployable, the 2010 mental disorders examiner stated that he is intermittently mentally unable to perform activities of daily living and, due to PTSD, cannot establish effective work relationships. Although the claims file reflects that non-service-connected leg and hip disabilities also result in impairment, the evidence is in approximate balance as to whether the Veteran's service-connected disabilities alone may render him unemployable. Due to the level of impairment from his PTSD and additional disability resulting from tinnitus and the residuals of his left hand gunshot injury, the Board finds that there is a state of approximate balance of the positive and negative evidence. As such, under 38 U.S.C.A. § 5107(b), the Veteran will be afforded the benefit of the doubt. A TDIU is therefore granted. (CONTINUED ON NEXT PAGE) ORDER A disability rating in excess of 50 percent for PTSD is denied prior to January 19, 2010. A disability rating of 70 percent for PTSD is granted from January 19, 2010. A total disability rating based on individual unemployability is granted. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs