Citation Nr: 1300970 Decision Date: 01/10/13 Archive Date: 01/16/13 DOCKET NO. 09-35 045 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with depression. 2. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1966 to May 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection and assigned an initial 30 percent rating for PTSD with depression, effective May 3, 2007. The Board notes that prior to that time, service connection was in effect for depression aggravated by diabetes, rated as 20 percent disabling from March 12, 2003. In an April 2011 rating decision, the RO denied the Veteran's claim for a TDIU. In his September 2009 substantive appeal, the Veteran requested a video conference hearing before a Veterans Law Judge at the RO. Thereafter, in a May 2012 letter, he requested that his hearing request be withdrawn. See 38 C.F.R. § 20.704 (d) (2012). As a final preliminary matter, the Board notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the appellant's claims. A review of the documents in such file reveals that they contain additional evidence that is relevant to the issues on appeal. Such evidence was previously considered by the RO and the Board notes that any future adjudication(s) should also take into account this paperless, electronic claims file. FINDINGS OF FACT 1. Since May 3, 2007, the Veteran's PTSD with depression has been manifested by depressed mood, anxiety, chronic sleep impairment, nightmares, irritability, anger, social isolation, mild memory loss, and hypervigilance; collectively, these symptoms suggest no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. Service connection is in effect for PTSD with depression (rated as 30 percent disabling), diabetes mellitus with hypertension, erectile dysfunction, and retinopathy and cataracts in the bilateral eyes (rated as 20 percent disabling), peripheral neuropathy of the right upper extremity (rated as 20 percent disabling), peripheral neuropathy of the left upper extremity (rated as 20 percent disabling), peripheral neuropathy of the right lower extremity (rated as 10 percent disabling), peripheral neuropathy of the left lower extremity (rated as 10 percent disabling), and residuals of an injury of the right thumb (rated as 10 percent disabling) with a combined disability rating of 80 percent. 3. The evidence indicates that the Veteran's service-connected disabilities are not so severe as to prevent him from engaging in substantially gainful employment of a sedentary or lightly physical nature. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 30 percent for PTSD with depression are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a TDIU are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in a September 2007 letter, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim for an increased rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter advised the Veteran to submit evidence from medical providers and statements from employers and others who could describe their observations of his disability level. The September 2007 letter also advised the Veteran of the necessity of providing medical or lay evidence demonstrating the level of disability and the effect that the disability has on his employment. The notice provided examples of pertinent medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. In a July 2010 letter issued prior to the adjudication of the TDIU claim, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim for a TDIU, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. Both issues were last adjudicated in May 2012. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the appeal. Pertinent medical evidence associated with the claims file consists of service treatment records, VA and private treatment records, and the reports of various VA examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran, and by his representative, on his behalf, as well as statements written by the Veteran's sister and a former Army colleague. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Thus, the Veteran was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, 353 F.3d at 1374; Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). A. Increased Rating for PTSD with Depression The Veteran was assigned a 30 percent rating for PTSD with depression, effective from May 3, 2007, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Diagnostic Code 9411 provides that a 30 percent rating is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 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- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or 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 the inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; 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. Id. The Global Assessment of Functioning (GAF) scale is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown , 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 indicates 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). A GAF score of between 51 and 60 indicates that the Veteran has moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 71 to 80 indicates, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). See DSM-IV. While the Rating Schedule indicates that the rating agency must be familiar with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV), VA does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Rather, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. The Veteran indicated in a September 2007 letter to VA that his psychiatric symptoms included trouble sleeping, feeling hopeless and jumpy, excessive sweating, work problems, nervousness, feeling sad and withdrawn, worsening of his chronic medical problems, and frequent arguing with his wife. In January 2008 the Veteran was afforded a VA psychiatric examination. The Veteran appeared clean and casually dressed. He reported that he felt depressed, tired, was overeating, and had feelings of hopelessness, although he denied any suicidal ideation. He reported that being diagnosed with diabetes "hit him hard" and that he often felt sorry for himself. He stated that he had a good relationship with his youngest daughter, but not with his other children, and that he had been married for 8 years and the marriage was going "so-so," because his wife was dealing with health problems as well. He stated that he had a mother living nearby and 6 sisters in various states, and that he had "okay" relationships with them, but had difficulty showing love, caring, and affection to his family. The Veteran reported that he felt anxiety in crowds and did not have many friends anymore, though he used to be much more outgoing. He reported having poor sleep, nightmares, acute anxiety, frequent irritability, and being upset by news of the war in Iraq. The Veteran's thought processes were logical and sequential, and he denied any homicidal or suicidal thoughts. The examiner wrote that the Veteran's symptoms also included recurrent and intrusive distressing thoughts, efforts to avoid thoughts, feelings, activities or people that arouse recollection of trauma, diminished interest in activities, feelings of detachment, and restricted range of affect. The examiner found that the Veteran had moderate, chronic PTSD and mild or moderate recurrent major depressive disorder and assigned him a GAF score of 60. The examiner ultimately opined that the Veteran's symptoms moderately affected his marriage, relationships with his adult children, and his overall social functioning, but did not significantly affect his work functioning. In an August 2010 VA general examination, the Veteran reported feelings of wanting to be alone, and the examiner found that the Veteran's occupational functionality was reduced due to poor social interactions. In August 2010 the Veteran was given a VA psychiatric examination, in which he appeared clean and casually dressed, with a cooperative and friendly attitude toward the examiner. The Veteran reported that his marriage and been deteriorating and that he was not close to any of his children. The Veteran also reported that he has gotten into altercations with his wife and has destroyed property when angry. The Veteran reported feeling misunderstood and that he did not like being around other people. He stated that he enjoyed reading but had no other leisure activities. He indicated that he had difficulty falling and staying asleep and had nightmares 4-5 times a week. He reported that he occasionally thought about homicide and suicide, but denied any plan or intent. He also reported that he sometimes forgets details, and that he has recurring intrusive thoughts about past traumatic events. The examiner found that the Veteran's symptoms included efforts to avoid thoughts, feelings, activities, and people associated with trauma, decreased interest in activities, feelings of detachment, irritability, exaggerated startle response, and hypervigilance. The examiner found that the Veteran had daily "mild to moderate" symptoms, with "occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks," and assigned the Veteran a GAF score of 60. The Veteran was afforded an additional VA psychiatric examination in November 2011. The Veteran appeared casually and appropriately dressed, his speech and eye contact were appropriate, and his attitude was cooperative and friendly. He reported that his marriage was "terrible" and that his wife was very argumentative, although there had been some improvement earlier when his wife began going to church. The Veteran maintained a relationship with his youngest daughter, but did not communicate with his other children and would not explain why. The Veteran reported that he attended church, watched television, and enjoyed reading, but that he was uncomfortable in crowds and did not have any friends. The examiner found that the Veteran's PTSD and depression caused nightmares, avoidance symptoms, sleep impairment, irritability, exaggerated startle response, hypervigilance, unhappy mood, loss of interest, sleep impairment, feelings of worthlessness, and loss of energy. He also found that the Veteran had feelings of detachment or estrangement from others, irritability or outbursts of anger, suspiciousness, and recurrent thoughts when viewing news about the wars in Afghanistan or Iraq. The Veteran reported that he had low self esteem and difficulty concentrating, but denied any suicidal ideation. The examiner found that the Veteran's symptoms were improving and that his symptoms had stabilized to the point where he had been discharged from psychotherapy and maintained only on medication. The examiner indicated that the Veteran had mild symptoms and "occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication," and assigned him a GAF score of 63. The Veteran has also been receiving regular psychiatric treatment at the Indianapolis VA Medical Center (VAMC). In a June 2006 psychiatric evaluation, the Veteran reported depression, overeating, sleep disruption, low libido, feelings of panic, and stress over his wife's illness. In a September 2006 treatment note the Veteran reported waking from nightmares in a sweat with increased frequency and feeling "down" due to the media coverage of the anniversary of 9/11. In an October 2007 evaluation the Veteran reported nightmares, social isolation, distressing anxiety four times a week, and intrusive thoughts. The Veteran was diagnosed with PTSD and major depression and assigned a GAF score of 60. VA treatment records from the Veteran's psychotherapy sessions which began in September 2006 show that the Veteran continued to report problems with nightmares, sleeplessness, intrusive thoughts, and anxiety. He often discussed feelings of frustration over his wife's health problems, family relationship problems, depression sparked by coverage of the wars, and dismay over not being as social as he used to be. In May 2008 he discussed ways that he had become more active, such as by walking in his neighborhood and gardening. In February 2009 the Veteran was accompanied to therapy by his spouse, who reported that she was trying to assist the Veteran to drink less and to communicate with him better. Although the Veteran often discussed his marital problems, in numerous sessions in 2011 he began reporting improvements in his relationship and overall communication and with his wife. VA records show his last psychotherapy session occurring in December 2011. In June 2009 the Veteran was evaluated by a psychiatrist who found him to be alert, fully oriented, and cooperative, with coherent and logical speech. The Veteran reported feeling distressing anxiety 4 times a week, as well as social isolation, intrusive thoughts, family relationship problems, and grief over the loss of his mother. He also reported that he had been maintaining better communication with his spouse and was engaging in family activities more often. The examiner assigned him a GAF score of 60. In a July 2009 treatment note, the Veteran reported feeling anxiety in crowds manifested by feeling sweaty, feeling guilty, and having occasional thoughts of harming himself or others, but with no specific plan or intent. In a January 2011 psychiatric assessment, the Veteran reported trouble with his memory but that he was more stabile and was now focusing on improving his continued relationship problems, including going to couples therapy with his wife. He also complained of feeling tired and run down due to nightmares and allergies which prevented him from sleeping. The Veteran was diagnosed with PTSD and partner relational problems and assigned a GAF score of 58. In a July 2011 treatment plan note, the Veteran's psychologist reported that the Veteran was maintaining stable functioning and had been putting more energy into improving his relationship with his spouse, with positive results. The examiner assigned him a GAF score of 63. In November 2011 the Veteran's psychiatrist recommended he be treated for alcohol abuse, and later in November 2011 the Veteran underwent a psychiatric evaluation for substance abuse. The examiner noted that the Veteran was in casual dress, spoke at normal rate and tone, and was cooperative. The Veteran reported that he had drank heavily after the death of his mother and that he was currently dealing with another tragic death in his family. The Veteran reported having symptoms of PTSD, but the examiner primarily discussed only findings relating to substance abuse. The examiner found that the Veteran did not need substance abuse treatment, although with his many other health problems, recommended that he should not be drinking at all. The examiner diagnosed the Veteran with PTSD, alcohol abuse, and major depression-recurrent, and assigned him a GAF score of 40. The Veteran withdrew from the substance abuse program in February 2012, and his discharge summary assigned him a GAF score of 55. In an April 2012 psychiatric assessment, the Veteran appeared cleanly groomed and dressed, cooperative, and with dysthymic mood and affect. He reported that the vividness of his dreams had decreased, but that he was continuing to have night sweats. The Veteran reported that he had stopped alcohol and nicotine use, but that he was still sleeping in a separate room from his wife. The Board has also considered the personal letters written on behalf of the Veteran. A "very close friend" and fellow Vietnam combat veteran wrote a letter to VA expressing his concern over the Veteran's "pain and suffering," flashbacks, and isolation from others caused by his combat experience. The Veteran's sister also wrote a letter indicating that the Veteran's temper and mood swings have become worse. She also stated that he sleeps poorly, becomes depressed while watching or reading news about the wars, has nightmares, and is quick to startle. After considering the above referenced VA compensation examination reports, VA treatment reports, and lay statements, the Board finds that the Veteran's service-connected PTSD with depression does not warrant a rating in excess of 30 percent. All of the Veteran's VA examination reports and treatment reports from his regular VA treatment providers consistently indicate that the majority of the Veteran's symptoms reflect that he has occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran has not currently demonstrated more than mild deficiencies in his ability to work. The Veteran indicated that his decision to retire from his previous job was due to his age, duration of employment, and other medical issues. While he has stated that he feels uncomfortable in crowds and has poor social skills, which may make some types of jobs more difficult for the Veteran, none of the Veteran's VA examiners found that the Veteran would have more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran is now retired, but he was able to previously work adequately at the same job for 35 years, and he has not asserted that his PTSD or depression has caused any impairment to his occupational productivity. Furthermore, the Veteran's judgment and thinking were always noted to be normal and logical and his conversation and eye contact were normal. His mood, at times, was noted to be depressed, and the January 2008 examiner noted the Veteran to have a restricted range of affect. However, the evidence of record shows that the Veteran was most frequently cooperative and friendly, and was never reported to have a flattened affect or circumstantial, circumlocutory, or stereotyped speech. The Veteran has reported feeling anxiety up to 4 times a week, although no examiner has classified these feelings as panic attacks, and the August 2010 VA examiner specifically noted that the Veteran's symptoms are more consistent with extreme anxiety rather than panic attacks. The Veteran has reported frequent irritability and mentioned in August 2010 that he has destroyed property during fights with his wife, but there has been no evidence of any episodes of violence or other types of inappropriate behavior. At no time has the Veteran displayed signs of spatial disorientation, delusions, or hallucinations. Throughout this time period, the Veteran has always been described as oriented and having adequate personal hygiene and appearance. The Veteran has stated that he has some mild memory loss, but has not demonstrated any impaired judgment, impaired abstract thinking, difficulty in understanding commands, or impairment of short- and long-term memory. While the Veteran has acknowledged having suicidal thoughts on a few occasions, such thoughts have been without any active plan or intent. They have been reported only intermittently, and none of the Veteran's treatment providers have indicated that such intermittent thoughts impair his functioning. The record contains no evidence of the Veteran ever attempting to harm himself, and none of the treatment providers have found him to be a threat to himself or to others. Most GAF scores assigned throughout the appeal period have reflected only moderate to mild symptoms and are not reflective of suicidal ideation. Thus, while not every symptom listed under the rating criteria for a specific evaluation needs to be present, the totality of the evidence reflects that this symptom, in and of itself, does not impact functioning such that a higher rating is more nearly approximated. Finally, the evidence demonstrates that the Veteran was able to establish and maintain some effective relationships. While he has reported that he has no friends or social activities, looking at the entirety of the evidence of record shows that the Veteran has been able to maintain some relationships and take part in and enjoy some activities. The Veteran has had a rocky relationship with his wife, but his VA psychotherapy records indicate that this was largely due to stress from his wife's health problems, and since 2011 their relationship has greatly improved. The Veteran and his wife attend church together, and she has been an active part in assisting his own treatment and recovery. The Veteran also has a positive relationship with his daughter and has reported that he is spending more time doing family activities. The Veteran reported feeling uncomfortable in social settings and sweating around crowds, but he has been able to enjoy attending church, first alone and later accompanied by his wife. The Veteran has also reported that he enjoys gardening, walking, and reading. When reviewing the symptomatology as a whole, the evidence fails to show symptoms that result in impairment which more nearly approximates the criteria for a higher rating of 50 percent. The Board acknowledges that a Veteran need not meet all or even most of the criteria for a higher rating for one to be assigned. However, the Veteran's psychiatric examinations and treatment records show that he has been able to be employed full-time with no impairment to his work, has normal and appropriate appearance, hygiene, and behavior, and has good concentration, thought process, judgment, memory, and abstract thinking. The majority of the evidence indicates that at no time has the Veteran demonstrated occupational and social impairment with reduced reliability and productivity due to his symptoms, and, while he has shown discomfort and difficulty in establishing and maintaining social relationships, he has been able to establish and maintain some effective relationships and social activities. Given these findings, the Board concludes that the weight of evidence shows that the Veteran's symptoms do not meet the criteria required for a rating in excess of the current 30 percent for PTSD with depression. See 38 C.F.R. § 4.130, Code 9411. The Board also points out that the Veteran's GAF scores are generally consistent with the assignment of no more than a 30 percent rating for PTSD with depression. The Veteran has been assigned GAF scores consistently ranging between 55 and 63, with one exception, which are reflective of no more than mild to moderate symptoms. While the Veteran was assigned a GAF score of 40 in November 2011, this score appears to be a clear outlier, is not supported in the examination report by any discussion of the symptoms or behaviors that would warrant such a finding, and does not appear to be an accurate representation of the Veteran's current disability level. Given the lack of objective testing or provided rationale to support the November 2011 GAF score, the Board assigns little probative weight to this treatment report. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship with other items of evidence). Furthermore, this GAF score was not assigned following a comprehensive psychiatric examination that evaluated the Veteran's PTSD or depression, nor was it performed by one of the Veteran's regular treatment providers who would be familiar with his psychiatric symptoms, which reinforces to the Board that the November 2011 GAF score is of far less probative weight than any of the many other competent and probative examination findings and GAF score assignments of record. In summary, for the reasons set forth above, the Board finds that the most probative evidence indicates that the Veteran's symptomatology is adequately addressed by the 30 percent evaluation presently assigned, and that entitlement to a rating in excess of 30 percent is not warranted at any time during the course of the appeal. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence. The rating criteria take into account interference with employment. Moreover, the Veteran informed the August 2010 and November 2011 examiners that he retired from his job due to age and other medical issues, and that his psychiatric disabilities were not a major factor in his decision to stop working. None of the examiners of record have found that the Veteran suffers from more than mild or occasional impairment in occupational functioning. The Veteran's disability picture is sufficiently contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). B. Entitlement to a TDIU VA will grant a total rating for compensation purposes based on unemployability (TDIU) when the evidence shows that the Veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. A total rating for compensation purposes may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the above purpose of one 60 percent disability or one 40 percent disability, disabilities of one or both of either the lower extremities or the upper extremities (including the bilateral factor) will be considered as one disability. 38 C.F.R. § 4.16(a)(1). For a Veteran to prevail on a claim for a TDIU, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See 38 C.F.R. 4.16(a); Van Hoose v. Brown, 4 Vet. App. 361 (1993). In determining whether an appellant is entitled to a TDIU, neither the appellant's nonservice-connected disabilities, nor advancing age may be considered. 38 C.F.R. § 4.19. In this case, the Veteran asserts that he is unable to work due to the severity of his service-connected disabilities. He has been granted service connection for PTSD with depression (rated as 30 percent disabling), diabetes mellitus with hypertension, erectile dysfunction, and retinopathy and cataracts (rated as 20 percent disabling), peripheral neuropathy of the right upper extremity (rated as 20 percent disabling), peripheral neuropathy of the left upper extremity (rated as 20 percent disabling), peripheral neuropathy of the right lower extremity (rated as 10 percent disabling), peripheral neuropathy of the left lower extremity (rated as 10 percent disabling), and residuals of an injury of the right thumb (rated as 10 percent disabling). The combined rating for all of the Veteran's service connected disabilities is 80 percent. The Veteran's peripheral neuropathy of the right and left upper extremities can be counted as a single disability, and combined this meets the criteria of at least one disability ratable at 40 percent or more with sufficient additional service-connected disabilities to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a). Thus, the Veteran meets the schedular criteria for a TDIU. Id. The record establishes that the Veteran has 35 years of work experience working for a trucking company assembly plant. Although the Veteran did not indicate any education or training on his August 2010 formal application for a TDIU, in a November 2011 examination at the Indianapolis VAMC he reported having two associates' degrees, and his VA records indicate that he has taken courses in Industrial Management and Hotel Management. Records from the Veteran's place of employment indicate that he retired from his job in October 2007. In August 2010 the Veteran filed a formal claim for a TDIU stating that he was prevented from securing or following any substantial employment due to his diabetes mellitus, peripheral neuropathy, PTSD, and tinnitus. The Veteran was denied service connection for tinnitus in April 2010, and in May 2012 he withdrew his claim for service connection for tinnitus. As the Veteran has not been granted service connection for tinnitus, it will not be considered as a factor towards his claim for a TDIU. See 38 C.F.R. § 4.16. In February 2006 the Veteran was instructed by a private physician that his diabetes mellitus required him to work no more than 40 hours per week. In July 2006 the Veteran was afforded a VA examination for diabetes mellitus, during which the examiner commented on this restriction, stating that the Veteran "does not have a significant limitation of activity, and even the restriction which is prescribed by his usual physician as a 40-hour workweek restriction is very mild." The Veteran was afforded a VA examination in September 2006 for the peripheral nerves. He reported that he had been experiencing numbness and tingling in his feet and that his job as a fork lift operator had been exacerbating his symptoms, and he therefore had to change to a different position with the company. The Veteran denied ever having employment which required repetitive motion with his hands or feet. In a VA psychiatric examination in January 2008 the Veteran reported that his psychiatric problems made it hard for him to socialize with people at work, that he tried to work alone whenever possible, and that while he had some friends at work, he was called a "loner." The Veteran denied any absences or significant problems at work, and reported that he was able to work for 35 years at the same company without any impairment in his work performance or reliability. The examiner ultimately found that there was occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks due to PTSD symptoms, but that "his symptoms did not significantly affect his past work functioning." In an August 2008 claim from the Veteran regarding residuals from an injury to his right thumb, the Veteran stated that the injury to his right thumb prevented him from gripping firmly and limited his ability to use the right hand in his employment, including making writing more difficult. In October 2008 the Veteran wrote to VA stating that his thumb injury prevented him from performing certain assembly jobs and that constant pain in his thumb and the inability to grasp tightly were factors that contributed to his retirement. Records from the Veteran's place of employment show that in July 2007 he was moved to a new job task requiring pushing wires into "glow plugs," which was very hard on his thumb and aggravated his injury, causing pain and a "popping and locking sensation." In July, August, and September 2007 he was treated multiple times at work for pain in his right thumb. The Veteran was given diagnoses of "osteoarthritis," "trigger thumb," "overuse vs. arthritis," and was given work restrictions that included not carrying more than 10 pounds, wearing a thumb splint, and avoiding repetitive, tight gripping. The Veteran was treated with a steroid injection, and in a September 2007 follow-up examination the physician found that the Veteran had "excellent improvement" and could resume his regular work duties. After the Veteran's retirement, records from the Indianapolis VAMC show that from June 2008 to August 2008 he continued to be treated for frequent pain and stiffness in his right thumb. In a December 2009 VA examinations of the peripheral nerves, the Veteran reported that he had retired due to age or duration of employment. In an August 2010 VA psychiatric examination, the Veteran reported to the examiner that he had stopped working due to age and other medical issues, but that his PTSD symptoms were not a major factor. The examiner found that the Veteran's PTSD caused occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks. In August 2010 the Veteran was given a VA general examination, and the examiner was asked to comment on each of the Veteran's service-connected disabilities and their impact on his ability to function in an occupational environment. The examiner noted that the Veteran felt he would not be able to work in a group environment due to his PTSD and depression, and the examiner opined that the Veteran's PTSD with depression would cause "poor social interactions." The examiner further noted that the Veteran's diabetes mellitus would cause lack of stamina, weakness, or fatigue, and that his peripheral neuropathy of the extremities would cause decreased mobility and manual dexterity. She also indicated that his residuals of an injury to the right thumb would cause decreased use of the hand and decreased manual dexterity, and his erectile dysfunction would have no effect on his occupational functioning. The examiner ultimately concluded that although he would be unsuited for "any type of employment of a strenuous nature due to decreased activity tolerance," none of the Veteran's disabilities "would totally preclude his participation in more sedentary type employment on a limited basis." The Veteran was afforded a VA eye examination in February 2011. The examiner found that though the Veteran had mild background diabetic retinopathy, he had 20/20 visual acuity in both eyes. The examiner stated that the disorder was not causing any functional impairment to the Veteran at that time. In November 2011 the Veteran was afforded an additional VA psychiatric examination. The Veteran reported that he worked at his company for 35 years before retiring in 2007 due to eligibility by age and duration of employment. The examiner found that the Veteran had "occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication." The examiner assigned the Veteran a GAF score of 63 and stated that his PTSD and depression did not render him unable to secure and maintain sedentary or physical gainful employment and that his symptoms were sufficiently mild that they would not interfere with employment. In December 2011 the Veteran was afforded an additional VA general examination. The examiner opined that the Veteran's diabetes mellitus and complications from diabetes mellitus, including erectile dysfunction and hypertension, did not have any impact on the Veteran's ability to work. The Veteran reported having severe pain in his right thumb approximately 3 times per week, and the examiner opined that the Veteran's right thumb arthritis would make gripping and holding items difficult. The Veteran reported that his peripheral neuropathy impacted his decision to retire from his job because it made him "clumsy," including not being able to grip and carry items and tripping more easily. The examiner found that peripheral neuropathy would cause decreased mobility, dexterity, and strength, but would not preclude the Veteran's ability to perform sedentary or light physical employment. Ultimately, the examiner opined that the Veteran would be able to "secure and maintain substantially gainful employment if that employment was sedentary or only require light physical employment activities." Based on the foregoing evidence, the Board finds that the Veteran's service-connected disabilities do not prevent him from obtaining and maintaining substantially gainful employment. While the Veteran asserts that he is unemployable, none of the numerous examination reports of record indicate that the Veteran is not capable of doing at least sedentary work, and the most recent VA examination also indicates that the Veteran could perform light physical activities. The Board acknowledges that the Veteran is limited in his ability to perform strenuous employment, primarily due to peripheral neuropathy which causes him to have decreased dexterity and strength. The Veteran's residuals of a right thumb injury may also preclude him from performing certain tasks that require repeated, stressful use of the right thumb. However, the competent and probative medical opinion in the record indicates the Veteran's disability does not prevent sedentary or lightly physical employment. The Board places greater probative weight on the medical opinion concerning the Veteran's employment capability than the Veteran's contentions as to the limitations caused by his disability. Again, the issue is not whether the Veteran is unemployed or has difficulty finding employment, but rather, whether the Veteran is capable of performing acts required by employment. See Van Hoose, 4 Vet. App. at 363. While the Board is cognizant that the Veteran may have difficulty working in a strenuous physical capacity, the preponderance of the evidence of record demonstrates that the Veteran is not precluded from securing and following substantially gainful employment of a less physical nature. Accordingly, the Board finds, based on the preponderance of the evidence of record, that the Veteran's service-connected disabilities do not preclude him from obtaining and maintaining substantially gainful employment of a sedentary nature consistent with his education, and the Veteran's claim for TDIU is denied. See 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). In reaching the above conclusion, the Board has again considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56 (1990). ORDER A rating in excess of 30 percent for PTSD with depression is denied. Entitlement to a TDIU is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs