Citation Nr: 1117193 Decision Date: 05/04/11 Archive Date: 05/10/11 DOCKET NO. 09-27 001 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to an initial rating in excess of 50 percent for depression. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD Tabitha G. Macko, Associate Counsel INTRODUCTION The Veteran, who is the Appellant, had active service from May 1969 to April 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, which denied service connection for hearing loss and for tinnitus, and which granted service connection for depression and assigned an initial disability rating of 50 percent. The Veteran disagreed with denials of service connection for hearing loss and tinnitus, and the initial rating for depression. FINDINGS OF FACT 1. Preexisting profound left ear hearing loss was noted on service entry examination. 2. Preexisting profound left ear hearing loss did not permanently increase in severity during service. 3. The Veteran was exposed to loud noise in service. 4. The Veteran did not experience chronic symptoms of right ear hearing loss in service. 5. The Veteran has not experienced continuous right ear hearing loss symptomatology since service separation. 6. The Veteran currently has hearing loss in the right ear to an extent recognized as a disability for VA disability compensation purposes. 7. The current right ear hearing loss is not etiologically related to exposure to noise in service. 8. Though the Veteran did experience noise in service during basic training, the Veteran did not experience chronic symptoms of tinnitus in service. 9. The Veteran did not experience continuous symptoms of tinnitus since service separation. 10. The current tinnitus is not related to loud noise exposure in service. 11. Throughout the initial rating period, the Veteran's service-connected depression symptoms are shown to be moderate in nature and more nearly approximate occupational and social impairment with reduced reliability and productivity and difficulty establishing and maintaining effective work and social relationships. 12. Occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships is not demonstrated at any time of the initial rating period. CONCLUSIONS OF LAW 1. The criteria for service connection for left ear hearing loss and right ear hearing loss have not been met. 38 U.S.C.A. §§ 1101, 1110, 1111, 1153, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306(a), 3.385 (2010). 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2010). 3. The criteria for the assignment of an initial rating in excess of 50 percent for the service-connected depression have not been met for the entire initial rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.130 Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Duty to Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). a. Duty to Notify. VA has a duty to notify the appellant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. In order to meet the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that the VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) held in Dingess v. Nicholson, 19 Vet. App. 473 (2006), that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include (1) the Veteran's status; (2) the existence of a disability; (3) a connection between the Veteran's service and the disability; (4) the degree of disability; and (5) the effective date of the disability. The Court held that upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim, and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. This notice must also inform the Veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. An October 2007 VCAA notice substantially satisfied the provisions of 38 U.S.C.A. § 5103(a). In this letter, the RO informed the Veteran about the information and evidence not of record that was necessary to substantiate his claims; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and the information required by Dingess. In regard to the claim on appeal for a higher initial evaluation for depression, the requirement of VCAA notice does not apply. Where a claim for service connection has been substantiated and an initial rating and effective date assigned, the filing of a Notice of Disagreement (NOD) with the RO's decision as to the assigned disability rating does not trigger additional 38 U.S.C.A. § 5103(a) notice. In this case, because the claim for service connection for depression, claimed as a mental disorder, has been substantiated, no further notice addressing the downstream disability rating requirement is necessary. In any event, the RO has provided the July 2009 statement of the case (SOC) that directly addressed the evidentiary requirements to substantiate the initial rating decision on appeal. Also, the evidence does not show that any notification deficiencies, with respect to either timing or content, have resulted in prejudice. The record raises no plausible showing of how the notice provided affected the essential fairness of the adjudication. Notwithstanding the boilerplate contentions, in the June 2007 statement and in the July 2009 substantive appeal, that VA was obliged to inform the Veteran of negative evidence and of how to "counter" this evidence, the VCAA imposes no such duty, and the Board finds the duty to notify the Veteran in this case is satisfied. b. Duty to Assist. The Board finds that all necessary assistance has been provided to the Veteran. The evidence of record indicates that the VA acquired the Veteran's service treatment records and the underlying medical evidence, from his 2002 application seeking disability benefits from the Social Security Administration, to assist the Veteran with his claims. The Veteran never reported seeking VA medical treatment for any disability, and he denied current treatment for his depression during the June 2008 VA mental disorders examination. The Veteran did complete VA Forms 21-4142 listing private mental health treatment including hospitalization from the 1980's to 2001 (see June 2008); however the records from the 2001 private hospitalization were already of record within the Social Security disability evidence, as well as an evaluation report from Dr. L, who counseled the Veteran in 2002 to 2003. Further, the report from Dr. L included the observation that the older treatment records from the 1980's hospitalizations were not found. In fulfilling the duty to assist, the Veteran was provided a VA audiological examination as well as a VA mental disorders examination in June 2008. These examinations were thorough and productive of medical findings regarding the nature and etiology of the claims for service connection for hearing loss and for a mental disorder, as well as to the severity of the Veteran's depression. The Board finds the Veteran's assertions in the addendum to his substantive appeal that VA failed to provide an examination or an adequate one too vague and sweeping to demonstrate inadequacy of the examination or to even raise a serious question or specific contention to which a response could be articulated. There is no indication in the record that the examiner was not competent. There is no indication of any irregularity with the examination. The Board finds the examinations legally sufficient. In view of the foregoing, the Board finds that VA has fulfilled its duties to notify and assist the Veteran in the claims under consideration. Adjudication of the claims at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Service Connection for Left Ear Hearing Loss Service connection generally requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. A veteran who served during a period of war, or after December 31, 1946, will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior to service and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. 38 C.F.R. § 3.306. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. §§ 3.304, 3.306. Of note is that the burdens and evidentiary standard to determine whether conditions noted at entrance into service were aggravated by service are different than the burdens and evidentiary standard to determine whether conditions not noted at entrance into service were aggravated. If a preexisting condition noted at entrance into service is not shown to have as likely as not increased in severity during service, the analysis stops. Only if such condition is shown by an as likely as not standard to have increased in severity during service does the analysis continue. In such cases, the increase is presumed to have been due to service unless there is clear and unmistakable evidence that the increase during service was not beyond the natural progression of the condition. See 38 C.F.R. § 3.306. 38 C.F.R. § 3.385 defines impaired hearing as a disability for VA purposes when the hearing thresholds for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz are 40 decibels or more; the thresholds for at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. The Veteran alleges that he was exposed to excessive noise levels in service when he was exposed to the noise of "bazookas," rifles, and after he had crawled too close to an "old foxhole full of plastic explosives" or "C4" that exploded, which resulted in his losing hearing in his left ear. See July 2007 statement; April 2007 VA Form 21-526. In this case, the Veteran's preexisting left ear hearing loss was noted at service entrance in May 1969. The Report of Medical History bears positive indications for ear trouble and for hearing loss, and on the reverse, the physician's summary, the examiner noted "deafness left ear since childhood" due to infection. The May 1969 pre-induction Report of Medical Examination noted the testing of his left ear as the following: HERTZ 500 1000 2000 3000 4000 LEFT 65 65 65 75 Despite his noted preexisting left ear hearing loss, the Veteran was deemed qualified for induction. Because the preexisting, severe left ear hearing loss was noted at service entrance, the Board finds that the presumption of soundness of the left ear at entry into service did not attach. 38 U.S.C.A. § 1111. In deciding a claim based on aggravation, after having determined the presence of a preexisting condition, the Board must first determine whether there has been any measured worsening of the disability during service, and then whether this constitutes an increase, permanent in nature, in the disability. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). The primary question then is whether the preexisting left ear hearing loss is shown to have permanently increased in severity during active service. In explaining the meaning of an increase in disability, the United States Court of Appeals for Veterans Claims (Court) has held that "temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered 'aggravation in service' unless the underlying condition, as contrasted to symptoms, is worsened." Hunt v. Derwinski, 1 Vet. App. 292, 297 (1992); see also Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002) (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare ups is not evidence of an increase in disability). Subsequent service treatment record entries reflect no worsening of preexisting left ear hearing loss; indeed, there are no requests for treatment or complaints at all about the Veteran's left ear, nor are there any requests for treatment after having crawled too close to an old foxhole full of plastic explosives that did explode. The sole reference to the Veteran's left ear was the notation, that he had been deaf in his left ear since the age of 6, included in the physical assessment section of the psychological evaluation that was included in the February 1970 medical boards' decision to recommend the Veteran's separation from service in 1970. The utter absence of complaints, findings, or treatment in service is further evidence that the preexisting left ear hearing loss did not permanently worsen in service. The April 1970 Report of Physical Examination included only a whisper test of both ears, which the Veteran was considered to have passed. As further evidence of lack of permanent worsening of preexisting left ear hearing loss by active service, the Board notes the private hearing loss evaluation the Veteran underwent in December 2007 reported the Veteran's statement of having experienced longstanding hearing loss for the previous 50 years after having had childhood illnesses that resulted in drainage from the left ear. That would approximately correspond with a 1957 onset, which would also correspond with the in-service psychological evaluation dated in 1970 that reported the Veteran's history as having been deaf since the age of six. The Veteran was born in 1950. The private evaluation dated December 2007 found the Veteran had profound hearing loss in the left ear. The private evaluation did not include an opinion regarding the etiology of either the left ear hearing loss or an opinion as to whether his service permanently aggravated the left ear hearing loss. Finally, the Veteran was afforded a VA audiological examination in June 2008. The claims file was reviewed. The VA examiner noted the 1969 testing results and considered them to show pre-existing moderately-severe to severe hearing loss in the left ear. The Veteran's hearing was tested as part of the 2008 examination and pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 LEFT 105 105 105 105 105 Speech audiometry revealed speech recognition ability of no percent in the left ear and the VA examiner categorized the left ear hearing loss as profound. The VA examiner noted the few references to the Veteran's left ear in the service treatment reports and the private December 2007 evaluation, in addition to the Veteran's reported post-service employment as a meat cutter and in woodworking, without hearing protection, and opined that there was no evidence the left ear hearing loss had been aggravated by his service. The Veteran has made several statements alleging that his left ear hearing loss both resulted from crawling too close to an old foxhole full of plastic explosives, that then exploded (see July 2007 statement), and that his hearing loss in general resulted from rifle fire (see August 2002 psychological evaluation, Dr. L, referring to losing "all" hearing in his right ear) and "bazooka" fire and a "C4" explosion. See April 2007 claim. Plainly these statements to VA and to other medical providers stand in stark contradiction to the objective record and are unsupported by the objective record, which includes the Veteran's own reported histories and complaints in service, and the absence of such complaints in service. As such, these statements lack credibility and are of no probative value. The Board has observed the Veteran's extensive mental health history and is mindful of his admitted difficulties with memory, hence the Board's finding is that these statements themselves are not credible. The Veteran also submitted two statements with parallel wording, dated October 2007 and signed by his two sisters. Both statements report the Veteran had a hearing "problem" before service, but that this problem was made worse by service. As neither sister explained how she knew severe hearing loss in the Veteran's left ear was made worse during service and was actually worse when he was separated from service, the Board finds their statements of little probative value. In this case, the Board finds that the weight of the evidence shows that the Veteran's preexisting moderately-severe to severe left ear hearing loss did not permanently increase in severity during service. As noted above, during his short service, the Veteran did not seek any treatment or make any complaint about his left ear hearing loss, which was moderately-severe to severe upon his induction. Further, that he was deaf in his left ear was noted in a 1970 psychological evaluation for his medical discharge board proceedings. Therefore, the Board finds that the weight of the evidence demonstrates that the Veteran's left ear hearing loss was not aggravated during service. In so finding, the Board notes that following service the Veteran obtained employment in the various jobs and never reported having sought medical treatment, or hearing aids, for his left ear. Further, despite more statements by the Veteran contending he was discharged from service due to his hearing loss, the Veteran contacted VA in late 1996 only to pursue getting a loan guarantee benefits, as acknowledged by the October 1996 letter of record from the RO to the Veteran. The Veteran did not submit a claim seeking service connection for hearing loss until over 10 years later, in April 2007. In short, the preponderance of the evidence of record is against a finding that the Veteran's preexisting moderately-severe to severe left ear hearing loss, which was noted at entrance into service, underwent any permanent increase in severity during service. For these reasons, the Veteran's appeal as to the issue of service connection for left ear hearing loss must be denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Right Ear Hearing Loss Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 38 C.F.R. § 3.385 defines impaired hearing as a disability for VA purposes when the hearing thresholds for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz are 40 decibels or more; the thresholds for at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. Sensorineural hearing loss may be presumed to have been incurred in service if shown to have manifested to a compensable degree within one year after the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that his current right ear hearing loss was due to acoustic trauma in service, again described generally due to rifle fire, "bazooka" fire, and an explosion of "C4". First, addressing the question of current disability, the Board finds that the Veteran has a right ear hearing loss "disability" in accordance with 38 C.F.R. § 3.385 for VA disability compensation purposes. Both the private December 2007 hearing loss evaluation and the June 2008 VA examination found mild to moderate right ear sensorineurial hearing loss, which qualifies as a disability under VA regulations. Specifically, on the authorized audiological evaluation in June 2008, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 20 50 50 Speech audiometry revealed speech recognition ability of 98 percent in the right ear. On the question of in-service injury or disease, the Board finds that the Veteran is shown to have been exposed to some loud noise in service. There is no indication the Veteran did not complete basic training, and his DD Form 214 indicates he was awarded the expert badge for the rifle (M-14). The Veteran did not serve in combat. His less than one year of service included nearly three months in a civilian jail for crimes while he was absent without leave (AWOL). However, the Board also finds that the weight of the evidence demonstrates that the Veteran did not have chronic symptoms of right ear hearing loss in service. His right ear hearing acuity was tested upon induction in May 1969. The Report of Physical Examination indicated the following results: HERTZ 500 1000 2000 3000 4000 RIGHT 05 -5 05 25 Service treatment records are negative for any complaints or treatment for right ear hearing loss. There is no request for treatment after being too close to a C4 explosion. The 1970 psychological evaluation report, prepared for the medical discharge board, noted the Veteran's physical assessment. That this evaluation recorded the detail that the Veteran was not only deaf in his left ear, but had been so since he was six years old, is evidence that his hearing was discussed with medical personnel. There is no mention of his right or other ear, nor of any complaint about his hearing, nor of any report of C4 explosions, and this after months of inpatient hospitalization. The April 1970 service separation examination report indicated only that the Veteran passed a whisper test for hearing. The Board next finds that the weight of the evidence demonstrates that right ear hearing loss symptoms have not been continuous since service separation in April 1970. As indicated, at the April 1970 service separation examination, the Veteran was deemed to have passed the whisper test. Further, the post-service evidence shows no history, complaints, findings, or diagnosis of hearing loss after service separation until many years later, in the private evaluation in December 2007. While the Veteran is competent to state that he had hearing loss symptoms at any time, including in service, the Board finds that the Veteran's more recent assertions of right ear hearing loss symptoms in service and continuous hearing loss symptoms since service, made in the context of the April 2007 claim for service connection (disability compensation) for hearing loss, are outweighed by the Veteran's own, more contemporaneous histories that he gave earlier and for treatment purposes. For example, the Veteran's recent statements of in-service and continuous post-service right ear hearing loss symptoms are inconsistent with private treatment records. Contained within the Veteran's Social Security Administration disability application are private hospital admission and emergency room reports dated June 2001. They are notable in their utter silence regarding any hearing loss. The psychiatric history and physical report, upon the Veteran's initial presentation to that hospital, even noted he had no major medical problems and the clinician described the Veteran was cooperative, sitting quietly and answering all questions with speech of a normal rate, rhythm and prosody. There is no indication the clinician knew the Veteran was deaf in his left ear, let alone had hearing difficulties in his right ear. As well, the Veteran sought counseling from Dr. L in 2002 and 2003 for his mental health problems. In March 2002 Dr. L prepared a psychological evaluation for the Veteran's then private attorney. This evaluation includes the Veteran's history, described as including many motor vehicle accidents, and the Veteran's report that while in service, he had lost all hearing in his right ear as a result of firing rifles held on the right side of the head. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). This confusion as to which ear was deaf is not evidence that supports the claim. Objective records clearly indicate the Veteran was deaf in his left ear. While Dr. L. may have erred in his notes, the additional detail that attributed the right ear loss of hearing to right-sided rifle fire could only have come from the Veteran himself, because he was the only person who would know how he held his rifle. Therefore, the Veteran had complained about only one ear's hearing loss, and mistook it for the right ear. As the Veteran was and is deaf only in one ear, his left ear, the Board cannot guess or assume that that means the other ear bothered him as well. The histories presented during private treatment do not include a mention of in-service hearing loss, continuous post-service hearing loss, or treatment of hearing loss symptoms or disability. See Cromer v. Nicholson, 19 Vet. App. 215 (2005) (upheld Board's denial of service connection and finding that a veteran's recent post-service account of in-service events was not credible because a veteran had previously given other histories and theories that did not mention the alleged in- service event, and first "came up with the story" years after service and in connection with the compensation claim). Again, the Veteran submitted two personal statements, dated October 2007, from his sisters attesting to his having had a hearing "problem" prior to service, but that his hearing became worse in service and was "definitely" worse when he was discharged and that this hearing loss has continued to make his life difficult for the Veteran. The sisters never explain how they knew that the Veteran's hearing became worse in service and has so continued. If their source was the Veteran himself, then as demonstrated by the reference in 2002 to the right ear having lost all hearing, the Veteran himself has had difficulty remembering which ear was deaf, which in turn does not make his statements pertaining to the severity of his hearing loss or the onset of right ear hearing loss credible. As also found earlier in this decision, the Board has found the Veteran's assorted post-service statements describing how his deaf left ear lost its hearing ability to be not credible, as these statements are unsupported by the objective record. Again, the Board finds these statements by the Veteran's sisters, as far as they may be applicable to the right, non-deaf ear, to have no probative value. The Veteran submitted a private December 2007 hearing loss evaluation. The private clinician gave no opinion as to the etiology of any hearing loss and noted only generally that the Veteran reported longstanding hearing loss for the previous 50 years, without specifying whether this broad statement applied to both ears or the one ear with profound hearing loss. As discussed above, the Board has found that 50 year history corresponds to the left ear being deaf since childhood. As the statements made to private clinicians in 2001, 2002, and 2007, were made during the course of treatment, they are afforded greater probative weight than those more recent statements made in conjunction with the Veteran's April 2007 claim for disability compensation benefits. For treatment, the Veteran would be expected to give a full and accurate history to get good treatment. In none of these evaluations does the Veteran mention a right ear hearing loss in service, symptoms in service, or continuous right ear hearing loss symptoms since service. See Rucker, 10 Vet. App. 73 (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate; statements made to physicians for the purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991); Pond v. West, 12 Vet. App. 341 (1991). In weighing the Veteran's statements of continuity of symptomatology made in conjunction with his current claim against the lack of continuity of symptomatology in the record from 1970 to 2007, the Board finds that the absence of contemporaneous medical evidence of continuity of symptomatology for almost 37 years is one factor, along with other lay and medical evidence stated above, that the Board has considered in finding that the Veteran's recent statements are less probative than the other evidence of record on the question of continuity of symptomatology after service. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). The Board further finds that the weight of the evidence demonstrates that the Veteran's currently diagnosed right ear hearing loss is not related to his active service. In the June 2008 VA audiological opinion, which weighs against the Veteran's claim, the examiner opined that, even recognizing the Veteran's in-service exposure to noise, the Veteran's current right ear hearing loss, diagnosed as moderate with excellent word recognition (98%), was not at least as likely as not incurred in or aggravated by service noise exposure. The VA examiner noted the Veteran's post service employment included employment as a meat cutter and in woodworking without hearing protection and that the service treatment records were void of any evidence to show the hearing loss was incurred during service. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The June 2008 VA audiological opinion is competent and probative medical evidence because it is factually accurate, as it appears the VA examiner was informed of the relevant evidence in this case, reviewed the claims file, relied on accurate facts, and gave a fully articulated opinion that is supported by a sound reasoning. Based on the evidence of record, there is no credible evidence of a relationship between the Veteran's current right ear hearing loss and his military service, including no credible evidence of continuity of symptomatology of hearing loss which would serve as a nexus to service. The only nexus opinion on file, in June 2008, which included a review of the claims file, weighs against the claim. Therefore, the Board finds that the lay and medical evidence of record weighs against the claim for service connection for right ear hearing loss, and outweighs the Veteran's more recent contentions regarding in-service and post-service hearing loss symptoms, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Tinnitus Certain chronic diseases, including such organic neurological disorders that cause tinnitus, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active military service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Veteran alleges that he didn't have ringing in his ears when he entered service, that he was diagnosed with hearing loss while undergoing inpatient treatment in service, that during service he was exposed to "bazookas" and C4 explosions, and now he has ringing in his ears. See April 2007 VA 21-526. After a review of the evidence, the Board finds that the Veteran was exposed to noise in service, and did not experience chronic symptoms of tinnitus in service. As discussed extensively above, while the Veteran completed basic training (he was authorized to wear the National Defense Service Medal), and so he was exposed to the noise appropriate to basic training, which includes some loud noise from small arms fire, the Board finds that the Veteran was not exposed to severe or traumatic noise levels. Further, his service treatment records contain no complaint or diagnosis of tinnitus, or complains of ringing in his ears, despite months of in-patient treatment which produced an evaluation so detailed, this evaluation noted he had been deaf in his left ear since the age of six. The Board finds that this detail indicates his hearing was discussed with medical clinicians and the Veteran did not report the symptom of ringing in his ears or some trauma after a "C4" explosion or "bazooka" fire. Following the Medical Discharge Board's recommendation that the Veteran be discharged for the good of the service, he was given a Report of Physical Examination in April 1970 that included the assessment of his head ears being clinically normal. There is no report of tinnitus or ringing in the ears upon service separation. The Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of tinnitus after service separation in April 1970. Private treatment reports in the claims file span from 2001 to 2003 (the Social Security Disability application underlying evidence), and then conclude with the private December 2007 hearing loss evaluation. The contents of the private reports are notable for their detail and complete lack of reference to any tinnitus symptoms. The existence of tinnitus was reported by the Veteran for the first time in the record on his April 2007 claim for service connection. Inconsistent with the Veteran's current, general assertions that he experienced continuous tinnitus since soon after service are the Veteran's failures to complain about tinnitus to any medical clinician prior to his claim seeking service connection. Even the October 2007 statements by his sisters contains no mention of any complaint of ringing in the ears at any time. The private December 2007 hearing loss evaluation noted the Veteran reported experiencing occasional tinnitus; however, with this disorder as well, the private clinician made no observation as to the onset of the tinnitus or its duration, and gave no opinion as to its etiology or relationship to service. The Board finds that the Veteran's omission in reporting tinnitus in either ear after service to any clinician, in the context of denial of tinnitus at service separation, is evidence that he did not experience symptoms of ringing in his ear continually after service. Though the Veteran was being seen for his mental health disorders, he reported a variety of events to these clinicians. The Veteran has described assorted motor vehicle accidents, the injuries he sustained therein, fights, period of unconsciousness, and his ability to stop abusing alcohol; however, through these various medical histories, he did not report any onset of ringing in his ears or that the ringing in his ears was been continuous since 1970. Such history as reported by the Veteran for treatment purposes is of more probative value than subsequent histories given during the current claim for compensation that were made solely for disability compensation purposes or pursuant to a compensation claim. Lay statements made when medical treatment was being rendered may be afforded greater probative value. See Rucker, 10 Vet. App. at 73 (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). The Board further finds that the current tinnitus is not related to noise exposure in service. The June 2008 VA audiological report has the opinion that the Veteran's tinnitus was not at least as likely as not due to service. In the June 2008 VA audiological examination, the examiner noted the Veteran appeared to be a poor historian and that, after having reviewed the claims file, the examiner was aware of his diagnoses of dementia from alcohol use and multiple vehicle accidents. The VA examiner also noted the Veteran's report that he had lost his left ear hearing during military exercises after C4 was detonated close by. The Veteran reported a recurrent, bilateral, but not constant, ringing, approximately once a week, with an onset at age 20. He reported his post-service employment as a substance abuse counselor and as a meat cutter, and lastly, as owning a woodworking business. After the severity of the current hearing loss was determined, the VA examiner opined the tinnitus was not at least as likely as not due to service, because nothing in the service treatment records that gave evidence that tinnitus was incurred or aggravated by service. The Veteran is certainly competent to report that he has experienced the symptoms of tinnitus; however, the Board finds that the failure to report any experience of tinnitus symptoms, specifically ringing in the ears to any practitioner contradicts that Veteran's current statements that he has experienced ringing in the ears since service. Therefore, the Board finds the Veteran's statements reporting an onset of tinnitus symptoms to 1970 to lack credibility, and to be of no probative value. For the reasons indicated above, the Board finds that the Veteran did not experience chronic symptoms of tinnitus in service or continuous symptoms of tinnitus after service separation. The evidence includes no complaints of tinnitus at service separation, post-service requests for treatment that did not include complaints or history of tinnitus, and a complete absence of evidence of complaints of tinnitus up to the time he filed the claim for compensation in April 2007. As the June 2008 opinion of the 2008 VA examiner was based on a review of the claims folder and that examiner's assessment of his reported noise exposure in service, the Board finds that this opinion is of probative value in demonstrating that the Veteran's tinnitus of post-service onset is not related to the in-service noise exposure. Medical findings or opinions linking the Veteran's tinnitus to service or any in-service event such as acoustic trauma are otherwise lacking. Accordingly, for the reasons described above, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for tinnitus, and the claim must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Initial Evaluation in Excess of 50 percent for Depression Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2010). Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. When a veteran appeals the rating initially assigned for the disability, after already having established service connection for it, VA must consider the propriety of a staged rating that is indicative of changes in the severity of the course of his disability over time. In the case of the assignment of an initial rating for a disability following an initial award of service connection for that disability (the circumstances of the present appeal), separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 125- 26 (1999) (recognizing a distinction between a veteran's dissatisfaction with an initial rating assigned following a grant of service connection and a claim for an increased rating of a service-connected disability). The VA rating schedule provides that psychiatric disorders, other than eating disorders, including depression (Diagnostic Code 9434), are to be rated according to a General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating may be assigned where 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; obsessed 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 work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9434. As noted below, treatment providers have rendered Global Assessment of Functioning (GAF) scores pursuant to the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV). As indicated in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995), the GAF is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. A score in the range of 51 to 60 indicates moderate symptoms (e.g., a flattened affect, circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., having few friends or having conflicts with peers or co-workers). A GAF score of 41 to 50 reflects a serious level of impairment (e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting), or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See also 38 C.F.R. § 4.126(a) (an evaluation shall be based on all the evidence of record that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of examination). In this decision, the Board considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has considered the symptoms indicated in the rating criteria as examples or symptoms "like or similar to" the Veteran's depression symptoms in determining the appropriate schedular rating assignment, and, although noting which criteria have not been met, has not required the presence of a specified quantity of symptoms in the Rating Schedule to warrant the assigned rating for depression. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In the appealed October 2008 rating decision, the RO granted service connection for depression and assigned a 50 percent initial disability rating effective July 19, 2007, the date of receipt of the Veteran's claim for service connection for a mental disorder. The Veteran contends that his depression symptoms are productive of a level of disability greater than what is contemplated by the initially assigned 50 percent rating. Relevant service treatment records were the Medical Board discharge proceedings, that appear to have been dated in February and March 1970, that recommended the Veteran's discharge from service, for the good of the service. The final diagnosis was schizoid personality. The evaluation report described the Veteran having a severe drinking problem before service. His relationship with his father was described generally as "poor," but was also described by the Veteran himself as abusive. The Board notes the father's January 1970 letter to his congressman remains in the personnel file, and in that letter, the father described his own son as having a "defect," whereas a letter from the Veteran's older brother, also to a congressman, refers to his own brother, now a 19 year old man, as simply "the boy." The Veteran had difficulty adjusting to military life and in September 1969 went AWOL. When he was found, he had been convicted of breaking and entering and had been incarcerated in a civilian jail until he was put on probation in January 1969 and released to military authorities. In the civilian jail he reported attempting suicide twice, and shortly after he was returned to his service, he broke restrictions, became intoxicated again, and was found in a suicidal condition. He was then brought to another service hospital for inpatient psychiatric treatment, where he remained from January to March 1970. Upon admission to the hospital in January 1970, the Veteran was found to be dejected, anxious, passive and timid. Affect was appropriate, he was not psychotic, though insight was nil and judgment was immature. During his hospitalization, he was quiet, withdrawn, and often appeared dejected. He seldom confronted other patients and never became involved with staff. He saw his future as bleak and feared doing something impulsive again, included the resumption of drinking. He was assessed as having a schizoid personality, manifested by reclusiveness, unsocialability, chronic low self-esteem and excessive alcohol ingestion. The Veteran was discharged in April 1970. The next treatment report was dated June 2001. The Veteran sought inpatient care at a private hospital (B) after becoming suicidal. He was initially assessed as suffering from acute situational depression, from financial distress. In reporting his history, the Veteran was married with two young children. He reported a long history of chronic and underlying depression. His woodworking business was floundering. He reported sleeping very poorly, having crying spells, and becoming more socially withdrawn than normal. He admitted to two prior suicide attempts, though the most recent was over 15 years prior. He had been treated for alcohol dependence, though he was now alcohol free for 20 years. He described his current spouse as his second and reported he had many friends and was well liked, though financially troubled. The clinician found him dressed appropriately, groomed, with a sad facial expression. His mood was severely depressed with a flat affect. Speech productivity and progression was well within normal range. Though his though content was suicidal, he was very guarded about his potential for suicide. Upon discharge he was assessed with adjustment disorder with depressed mood, and alcohol dependency in remission. In the hospital, he was cooperative, pleasant, and actively participating is all groups. He now denied any suicidal thoughts or plans. He was oriented for the future and talked about starting a new job. The Veteran's then treating therapist, Dr. L., provided a March 2002 psychological report. He described the Veteran as having been married 3 times, and having had four children, though only two in the current marriage. Dr. L. discussed the Veteran's abusive childhood, which included verbal and physical abuse from an alcoholic father. The Veteran was left with limited control over feeling rage and from preventing that rage from leading to physical aggression. Dr. L referred to the Veteran's service as a time of drinking, experiencing blackouts, criminal arrests and inpatient psychiatric care. The Veteran also described a number of motor vehicle accidents which routinely involved serious head injury and periods of unconsciousness. Post-service he worked as a butcher for years until the 1980's when that employment ended. Then again the Veteran attempted suicide, received inpatient care and became sober. He resumed work again in 1981 as a meat cutter and discovered he had little memory, which required him to leave that employment. He then found work in a series of residential treatment centers and hospitals as a technician or as a counselor. At one facility, he found he was unable to remember simple details and had to compensate by writing everything down. Apparently he thrived in supportive environments and received good performance reviews that noted his ability to get along with staff and patients. He also reported concurrently great difficulty remembering details and procedural steps. From 1996 to 2000 he worked at a drug rehabilitation center as a crisis specialist. He was fired in 2000 due to falling asleep at work and his inability to remember detail and correctly follow procedural steps, sequences, and didactically based staff training. He then attempted to build up his woodworking business. He was able to get work in 2002 as a car salesman, but was again fired for losing keys and being unable to remember details such as car prices. His final boss berated him in front of customers and the Veteran walked away from the job. Dr. L noted his therapy focused on depression and the Veteran's low-self esteem, which Dr. L regularly attributed to the Veteran's abusive father, and the Veteran's tendency to detach himself and isolate. In Dr. L's report, the Veteran's service was noted in passing and only the Veteran's right ear hearing loss was attributed to service. In November 2002 the Social Security Administration granted him disability benefits, indicating the primary diagnosis was dementia due to traumatic brain injury and alcohol. The secondary diagnosis was recurrent major depressive disorder. The October 2002 assessment of his current mental status noted he arrived alone for the appointment, had no difficulty find the office, demonstrated good hygiene and made good eye contact. He described his list of jobs, noted he had been fired from each one and usually fired for forgetting details, disregarding rules, being inattentive, or making errors. The private examiner found him oriented, presented as dependent, with pressured speech, though not rapid; he would frequently lose his train of thought and had difficulty moving from one thought to another. He had poor focus and concentration. He denied hallucinations and delusions, though he reported suicidal and homicidal urges. Upon testing, his immediate and recent memory was incomplete, though he answered the past memory questions correctly. The final diagnosis was dementia due to traumatic brain injury and alcohol abuse, major depressive disorder, recurrent, and alcohol dependence, in full remission. There was no Axis II diagnosis; however for Axis III the examiner noted numerous brain insults. Axis IV was childhood abuse, difficulties with wife, and loss of employment. She assigned a GAF of 35. Within this entire report, the Veteran's military service was not referenced once. The Veteran was afforded a VA mental disorder examination in June 2008. There were no intervening mental health treatment reports to obtain, as the Veteran denied seeking any treatment. The claims file was reviewed. The Veteran's abusive childhood, alcohol abuse, brief service with AWOL and inpatient psychiatric treatment, history of traumatic brain injury and suicide attempts were all noted, as well as the Veteran's report that he was now divorced for the third time. The VA examiner found the Veteran clean and casually dressed. His speech and psychomotor activity were unremarkable. While he was cooperative and attentive, his affect was constricted, and mood was anxious. He was easily distracted and his attention span was short. He was unable to do serial 7's. He was fully oriented and his thought process and content were unremarkable. He had no delusions and his judgment was that he was able to understand the outcome of his behavior. He described his sleep as restless. He had no obsessive or ritualistic behavior, no panic attacks, and no presence of homicidal or suicidal thoughts. The examiner found his impulse control good. He had a history of 5 suicidal attempts, but the examiner found him no longer suicidal. His remote, recent, and immediate memory were mildly impaired; however, the Veteran reported his memory was better when he was relaxed. The examiner also noted he no longer abused alcohol and did help to take care of his children. The VA examiner noted the Veteran was not employed, but was retired due to a psychiatric problem, which the VA examiner diagnosed as posttraumatic stress disorder (PTSD), secondary to childhood trauma. That was the VA examiner's Axis I diagnosis. He also found depression NOS and a suicide attempt in service. For Axis III, the VA examiner also found traumatic brain injury secondary to a motor vehicle accident. While the examiner assigned a GAF of 40 to the Veteran's PTSD, secondary to childhood trauma, he assigned a GAF of 60 for the depression with suicide attempt in service. The examiner attributed total occupational and social impairment as mostly due to the PTSD, secondary to childhood trauma. He noted the Veteran had been able to marry, have children, that his memory improves when he is relaxed and to hold some jobs before he went out on disability. The examiner placed the in-service suicide attempt as a time when the Veteran was very depressed and when everything looked hopeless. After a review of the evidence, lay and medical, the Board finds that, throughout the initial rating period, the Veteran's service-connected depression symptoms are shown to be moderate in nature and more nearly approximate occupational and social impairment with reduced reliability and productivity and difficulty establishing and maintaining effective work and social relationships. Such impairment and symptoms are consistent with a 50 percent disability rating under Diagnostic Code 9434. 38 C.F.R. § 4.130. The GAF score assigned for the service-connected depression was 60. According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 2000) (DSM- IV-R), a GAF score in the 51 to 60 range is indicative of moderate symptoms or moderate difficulty in social and occupational functioning. The assigned GAF score is consistent with the criteria for a 50 percent rating reflecting at minimum a moderate level of impairment. The Veteran post-service had been regularly employed, usually for years in the same position, in jobs at treatment facilities that required he interact with other people. He did marry three times over the course of 30 years and have four children. Though currently divorced, the 2008 VA examiner noted he was able to help care for his children. Although the Veteran has difficulty with his social relationships, it does not appear that he has an inability to establish and maintain effective relationships. The Veteran reported to the June 2008 VA audiological examination examiner that he still had his woodworking business, which was described in the record as making furniture. He was found to have a flat affect and only restless sleep. The 2008 VA examiner noted the Veteran reported flashbacks and intrusive thoughts, but those were of his abusive childhood. Though anxious, his thinking was logical and linear. Every examiner in the record found him to be clean and have good hygiene, pleasant and cooperative. The June 2008 VA examiner also found he did not have panic attacks and that he was no longer suicidal. The Board finds significant that both the June 2008 VA examiner, as well as the October 2002 mental health evaluator (for the Social Security disability benefits application) found dementia, secondary to traumatic brain injury. The Veteran is not service-connected for dementia, secondary to traumatic brain injury, nor is he service connected for PTSD, secondary to an abusive childhood. Whereas, when it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability, clearly this is an appeal in which the symptoms of impaired memory have been plainly, and without contradiction, attributed to a non-service connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). The Veteran himself attributed his difficulties remaining employed to his impaired memory. See October 2002, mental health evaluation, March 2002 psychological evaluation, Dr. L. The Board finds that there is no indication in the record that his current lack of employment was due to the Veteran's depression. In addition, the Board finds that the degree of occupational interference due to service-connected depression was fully contemplated by a 50 percent disability initial rating under Diagnostic Code 9434. The Board further finds that at no time during the rating period has the Veteran's depression symptomatology more nearly approximated occupational and social impairment with deficiencies in most areas, as required for a higher disability rating of 70 percent under Diagnostic Code 9434. The evidence does not demonstrate for any period 70 percent symptomatology such as obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; spatial disorientation; or neglect of personal appearance and hygiene. While suicidal ideation is one of the factors for consideration for a 70 percent evaluation, it is apparent that any suicidal thoughts for the most part were in the distant past, the most recent being in 2001. The VA examiner in 2008 noted the Veteran longer had any suicidal or homicidal thoughts. Absent any showing of the other criteria for a 70 percent evaluation, the evidence of a history of suicidal ideation in this case is insufficient to support such an evaluation. See 38 C.F.R. § 4.126(a). While there does appear to be some stabilization of the Veteran's symptomatology during the course of the appeal, as reflected in the Veteran's June 2008 VA examination, the Board finds that the evidence also reflects that the disability level during the entire course of the appeal has consistently more closely approximated the criteria for a 50 percent evaluation than that for a 70 percent evaluation. See 38 C.F.R. § 4.7. It is for this reason that the Board has also determined that staged ratings are not warranted in this case. Given the facts in this case, the Board finds that the Veteran's depression is appropriately rated as 50 percent disabling, and no higher, for the entire initial rating period on appeal. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether an extraschedular evaluation would have been warranted for depression. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2010). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, 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. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's service-connected depression is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9434, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's depression has manifested difficulty sleeping, anxiety, flat affect, a past history of suicide attempts, some difficulty maintaining social relationships and a tendency to isolate. These symptoms are part of the schedular rating criteria. In addition, the level of occupational and social impairment is explicitly part of the schedular rating criteria. In addition, the GAF score is incorporated as part of the schedular rating criteria as it tended to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] 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." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with depression, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Further, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a TDIU claim may be part of an increased rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. In this case, the Board finds that a claim for a TDIU, although a form of extraschedular rating, is not raised by the Veteran or the evidence of record. While the Veteran was found by the Social Security Administration in its November 2002 determination to be disabled and the Veteran reported to SSA that he had last worked (for the car dealership) in April 2002, the Veteran reported to the June 2008 VA audiological examination examiner that he owned a woodworking business. On the same day, he was afforded the VA mental disorders examination and to that examiner he reported that he was retired, that his usual occupation was as a car salesman. As the record is not at all clear as to the Veteran's employment status, the Board will not remand to develop a TDIU claim. ORDER Service connection for hearing loss is denied. Service connection for tinnitus is denied. An initial evaluation in excess of 50 percent for depression is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs