Citation Nr: 1301302 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 08-17 061 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York THE ISSUES 1. Entitlement to an initial disability rating for posttraumatic stress disorder (PTSD) in excess of 50 percent. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant (the Veteran) is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from November 1943 to October 1947, from August 1948 to January 1950, and from August 1950 to February 1952. This appeal comes before the Board of Veterans' Appeals (Board) from a December 2006 rating decision of the RO in New York, New York, which granted service connection for PTSD, and assigned an initial rating of 10 percent, effective October 18, 2004. The initial rating was subsequently increased to 50 percent, also effective October 18, 2004. Thus, the appeal does not involve a staged rating for PTSD. This appeal also arises from an April 2009 rating decision of the RO in New York, New York, which denied a TDIU. Although the Veteran requested a Board hearing in the February 2010 VA Form 9, he subsequently withdrew his request for a hearing. In reviewing this case, the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2012). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. For the entire period of this appeal, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity. 3. For the entire period of this appeal, the Veteran's service-connected disabilities have not rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating higher than 50 percent for PTSD have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a TDIU have not been met for any period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist 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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his/her representative, if applicable, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Further, in Dingess v. Nicholson, the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. Concerning the appeal for a higher initial rating for PTSD, because it arises from the Veteran's disagreement with the initial evaluation following the grant of service connection, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the CAVC have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for 'downstream' issues following a service connection grant, such as initial rating and effective date claims). Regarding the claim for TDIU, the Veteran submitted his claim in May 2008. He was sent a letter in August 2008 which advised him of the information and evidence necessary to substantiate his claim. That letter also advised him as to how disability ratings and effective dates were assigned in the event of a successful claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Since the August 2008 letter was sent to the Veteran prior to the initial adjudication of the claim in April 2009, there exists no error in the timing of this notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). In short, VA has complied with its duty to notify the Veteran in this case. VA has also fulfilled its duty to assist the Veteran by obtaining identified and available evidence needed to substantiate the claims. The information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, and the Veteran's written assertions. VA afforded the Veteran several VA examinations, the most recent in September 2011. The Board finds that the Veteran has been afforded an adequate VA examination and opinion in this case. The examination was performed by a medical professional based on a review of claims file, solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The resulting opinion and rationale were consistent with the examination and the record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The Board acknowledges that the Veteran applied for and was receiving disability benefits from the Social Security Administration (SSA) prior to switching to retirement benefits. However, certification from SSA was obtained in July 2008 that those benefits were granted for gastritis and duodenitis. These are not service-connected disabilities. When VA has actual notice of the existence of relevant SSA records, the duty to assist includes requesting those records from the SSA. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010); however, in Golz, the Federal Circuit elaborated on the term "relevant" holding that not all SSA disability records must be sought-only those that are relevant to the veteran's claim; and, to conclude that all SSA disability records are relevant would render the word "relevant" superfluous in the statute. The Federal Circuit specified that relevant records for the purpose of § 5103A are those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the claim. In Golz, the claimant was seeking service connection for PTSD. The Federal Circuit held that records relevant to his claim were those relating to a medical diagnosis of PTSD, evidence corroborating claimed in-service stressors, or medical evidence establishing a link between any in-service stressor and a PTSD diagnosis. In that case, where SSA disability was awarded solely on the basis of a back disorder, the Federal Circuit held that the CAVC did not misinterpret 38 U.S.C. § 5103A in affirming the Board's finding that SSA records were not relevant. Here, the Board finds that SSA records pertaining to nonservice-connected gastritis and duodenitis are not relevant to the Veteran's claims seeking an increased rating for PTSD or seeking a TDIU. Disability Ratings - Laws and Regulations 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. 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. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In the process of evaluating a mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran's psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors, and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Analysis of Initial Rating for PTSD The current appeal arises from a claim for service connection received at the RO on October 18, 2004. In the December 2006 rating decision, the RO granted service connection and assigned an initial 10 percent rating for PTSD, pursuant to Diagnostic Code 9411, effective October 18, 2004. In an April 2008 decision, the initial rating was increased to 50 percent, also effective October 18, 2004. In the process of evaluating a mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran's psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors, and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering. The VA Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the VA Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The schedular criteria incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Pertinent to the claim on appeal, the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: a 10 percent rating is warranted for PTSD if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is warranted for PTSD if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted if it is productive of 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 compete 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 for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent rating contemplates 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 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score of 41-50 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 51-60 indicates "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)." A GAF score of 61-70 indicates "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, has some meaningful interpersonal relationships." After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran's PTSD is not manifested by occupational and social impairment, with deficiencies in most areas, or by total occupational and social impairment, but most closely approximates occupational and social impairment with reduced reliability and productivity. In essence, while the Veteran's symptoms do impact areas such as family relations and mood, the impact appears to be occasional; moreover, the Veteran does not appear to have significant deficiencies in judgment and thinking. The Veteran has identified his primary concerns as anxiety and depression, as well as irritability and memory impairment. In correspondence with VA, the Veteran reported that he could not keep his job as a doorman because people said he flared up whenever anything was said. He reported that he forgets what he is saying in mid sentence and has unhappy dreams of the war. September 2005 and October 2005 VA behavioral health outpatient notes reveal that the Veteran was experiencing nightmares of dead bodies and a sense of impending disaster, as well as survivor grief and guilt. The Veteran was diagnosed with PTSD. His affect was found to be sad but appropriate. His mood was depressed and anxious. However, his speech was normal; thought processes were intact; there were no hallucinations or delusions; there was no suicidal or homicidal ideation; the Veteran was fully oriented to person, place, and situation; his recent and remote memory was intact; his cognitive function was intact; abstraction, judgment, and insight were each intact. A September 2007 behavioral health note reveals that the Veteran's mood was good; affect was congruent; his anxiety was described as manageable with no lasting hopelessness. A November 2007 behavioral health note reveals that the Veteran complained that he avoided being around others because they ask him to recount his experiences from the war. The Veteran was described as well groomed, alert, oriented, motivated, and engaged; his affect was worrisome and his mood was anxious; however, thought processes and memory were intact and his insight was good. The Veteran denied suicidal ideation or homicidal ideation. A December 2007 behavioral health note reveals that the Veteran was oriented, and his affect was bright; his mood was somewhat anxious; his thought processes and memory were intact; his insight was good; he denied suicidal ideation or homicidal ideation. Treatment reports in 2008 reveal what are described as obsessive thoughts concerning the Veteran's appeal of the initial rating for PTSD. The report of VA examination in April 2008 reveals that the Veteran was casually dressed, displaying good grooming and hygiene. The Veteran spoke in a clear-voiced tone, at a slow rate of speed. He had a rather small speaking vocabulary, but had adequate receptive and expressive language skills. The examiner administered tests of short-term memory and discussed current events, world affairs, etc. These discussions revealed that the Veteran had a good understanding of current events; he was able to speak intelligently about the war in Iraq and the upcoming presidential election. The Veteran described himself as having been depressed for the past two years. He described his temper as irritable and subject to flare ups, during which he simply yells. He reported that he is not aggressive, destructive, or violent. The Veteran was asked about visual and auditory hallucinations and reported that he sometimes feels like there is somebody in the room who calls his name. He reported seeing shadows that remind him of a snake. He was not clear whether these are a vivid imagination, the result of simply living alone, or true auditory or visual hallucinations. The Veteran denied any paranoia or other delusional thinking. The Veteran reported that he becomes anxious when he is around a lot of people, and it is crowded and noisy. He stated that he avoids crowds. In contrast, he also reported that he lives in a six-apartment building and apparently enjoys the company. The Veteran stated that he suffers from severe insomnia and often wakes up at night and just looks at the clock. He reported that he wakes up almost every two hours. The Veteran denied ever being suicidal or homicidal. He reported that in 2004, while in Florida, he was locked up overnight because he got belligerent with a police officer. The examiner found the Veteran to be seriously impaired in his overall functioning and assigned a GAF score of 41. It was the examiner's opinion that the Veteran was unemployable, and that his PTSD played a role in his taking early retirement. According to the examiner, the Veteran's PTSD no doubt contributed to his anxiety, which has caused impairment in social functioning, as well. The report of a VA examination September 2011 reveals the presence of symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting, suicidal ideation, and neglect of personal appearance and hygiene. The Veteran reported that he has some friends, and that he interacts with people, but is reluctant to do so. In the interview with the examiner, the Veteran was found to be gregarious and friendly with the staff; he joked with the clerks and complimented the women. The interviewer found no difficulty in the Veteran's ability to interact with others, and found him to be very social. The examiner found that the Veteran's level of impairment was best described as occupational and social impairment with reduced reliability and productivity. The Veteran's current global assessment of functioning (GAF) score was 60. The Board notes that there are some discrepancies in the evidence as reported by the VA clinicians in this case. First, the September 2011 VA examiner marked the box indicating that the Veteran displays a neglect of personal appearance and hygiene. However, this conflicts with every other account of record. The April 2008 examiner found that he displayed good grooming and hygiene. A November 2007 behavioral health note indicates that he was neatly dressed and well groomed in a shirt and tie. The Board notes that the September 2011 provided no description of the Veteran's appearance in support of his finding, but simply checked a box on a pre-printed form. Consequently, the Board accords this finding less weight than the specific descriptions of the April 2008 examiner and November 2007 behavioral health clinician. The September 2011 examiner also checked a box indicating that the Veteran experiences suicidal ideation. This conflicts with the other examinations. Notably, the Veteran denied ever being suicidal to the April 2008 VA examiner. As the September 2011 report is simply a check box with no description of actual symptomatology, the Board accords this evidence lesser probative weight than the more detailed descriptions in the other reports. A September 2006 behavioral health note reveals an experience during the night when the Veteran woke and thought he saw a snake or a person, then realized that no one was there. He reported that the incident did not last long. The examiner commented that it seemed more illusory than hallucinatory. The Veteran was not overly concerned about the incident. Based on his description, this symptomatology, to the extent it exists, does not appear to affect the Veteran's occupational or social functioning. The main outlier in the evidence appears to be the April 2008 examiner's assignment of a GAF score of 41, and the examiner's opinion that the Veteran's PTSD played a role in his taking early retirement and contributed to his anxiety, which has caused impairment in social functioning, as well. The GAF score of 41 is indicative of 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). The April 2008 GAF score contrasts sharply with the GAF score of 60 assigned by the September 2011 examiner. The Board must determine whether this represents a true improvement in symptoms since the April 2008 examination, or whether one of the scores should be discounted. In this case, the Board finds that the April 2008 VA examiner's GAF score of 41 is not supported by the symptomatology reported in the April 2008 examination. Notably, while a GAF score of 41 contemplates suicidal ideation, the April 2008 examiner specifically noted that the Veteran denied ever being suicidal or homicidal. He reported irritability, but noted that he simply yells and is not aggressive, destructive, or violent. While he reported an episode of being jailed because of becoming belligerent with officers, this reportedly occurred in 2004, and he has not reported any subsequent incidents. While he has reported that he had to stop working due to conflicts with his employer, difficulty in establishing and maintaining effective work relationships is specifically contemplated as a symptom example for the 50 percent level, and the Board finds that the Veteran's reported behavior better fits this example than it does impaired impulse control (such as unprovoked irritability with periods of violence). The Veteran reported severe insomnia to the April 2008 examiner; however, sleep impairment is a symptom example under the 30 percent level. In short, the level of symptomatology reported by the April 2008 examiner is generally consistent with that reported in September 2011. The Board finds that the April 2008 examiner's GAF assessment is inconsistent with the symptoms reported even on that report. Regarding the April 2008 examiner's opinion that the Veteran's PTSD played a role in his retirement, this is not probative of any particular rating. Occupational and social impairment are contemplated under the criteria for all compensable levels under Diagnostic Code 9411. In sum, the Board finds that, while there are some discrepancies in the clinical findings of record, these do not represent a true difference in the level of symptomatology, but reflect differences in the interpretations of the examiners. In light of the consistently good findings for speech, thought processes, orientation, memory, and cognitive function, the Board finds that the Veteran's level of PTSD symptomatology most closely approximates occupational and social impairment with reduced reliability and productivity. While the Veteran believes that his memory is impaired, this is not supported by specific memory testing. The September 2011 VA general medical examiner described the Veteran as a poor historian; however, the Board finds the testing conducted by the April 2008 VA examiner to be more persuasive than the September 2011 examiner's unexplained notation. For these reasons, the Board finds that the weight of the evidence is against a disability rating in excess of 50 percent for PTSD. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2012), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected PTSD. All the Veteran's PTSD symptoms are either explicitly part of the schedular rating criteria under the general formula for rating mental disorders at 38 C.F.R. § 4.130; are analogous to the schedular rating criteria (see 38 C.F.R. §§ 4.20, 4.21), or are "like or similar to" the schedular rating criteria (see Mauerhan at 442-43). The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. The Veteran's symptoms of irritability, social withdrawal, depressed mood, anxiety, suspiciousness, and chronic sleep impairment are specifically included in the rating schedule, and the assigned 50 percent disability rating specifically rates based on the degree of occupational and social impairment, including due to specific symptomatology. The GAF scores indicated in the DSM-IV, which reflect overall degree of impairment due to psychiatric disorders, and which the Board weighed and considered in this case, are part of the schedular rating criteria. Because the schedular rating criteria are adequate to rate the Veteran's service-connected PTSD, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Analysis of TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. Substantially gainful employment is that employment which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the claimant resides. Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). In evaluating a veteran's employability, consideration may be given to his level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or impairment caused by non service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Here, the Veteran has four service-connected disabilities - PTSD, rated at 50 percent, post-operative nephrolithiasis, rated at 30 percent, a right hernia scar, rated at 10 percent, and non-scar hernia residuals, separately rated at 10 percent. The Veteran therefore has one disability rated at least 40 percent, and a combined disability rating of 70 percent. Thus, the Board finds that the Veteran meets the schedular criteria for consideration of a total rating based on individual unemployability due to service- connected disabilities. See 38 C.F.R. § 4.16(a). Next, the Board has considered whether the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran's service-connected disabilities do not render him unable to secure and follow a substantially gainful occupation. A September 2011 VA general medical examination reveals that that Veteran had a pulling sensation in the groin areas bilaterally on an infrequent basis that could last hours at a time. He had not passed any renal stones since his hernia surgery in the 1950s. In 1996, he had a renal ultrasound which revealed some shadowing suggestive of a small right renal calculus with no hydronephrosis. The examiner's review of VA clinical records over the prior decade revealed no ongoing clinical issues with recurrent renal stones or symptoms related to his past hernia repairs. The examiner opined that the service-connected conditions would not have any effect on employment of any kind. He further found that prostate and genitourinary symptoms reported by the Veteran are unrelated to the service-connected conditions. An August 2008 VA examiner found that the Veteran's hernia residuals resulted in mild impairment regarding chores, shopping, exercise, recreation, traveling, and toileting, but no impairment regarding sports, feeding, bathing, dressing, and grooming. The nephrolithiasis resulted in mild impairment regarding recreation, traveling, and bathing, moderate impairment regarding toileting and grooming, and no impairment in chores, shopping, exercise, feeding, dressing, or driving. Sports were prevented. The Board acknowledges that SSA has found the Veteran to be disabled; however, as noted above, this was entirely based on nonservice-connected disorders. The Veteran's service-connected disabilities were not a factor in SSA's determination. The Board acknowledges the April 2008 VA examiner's opinion that the Veteran was unemployable, and that his PTSD played a role in his taking early retirement; however, this falls well short of an opinion finding that the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. It essentially restates what the Board has already found, which is that the Veteran's PTSD has resulted in occupational impairment; however, it assigns no particular importance to the Veteran's PTSD in causing unemployability, as compared to his nonservice-connected disabilities. As such, the opinion is inconclusive on this question. In sum, with the exception of the Veteran's PTSD, the Veteran's service-connected disabilities do not significantly contribute to occupational impairment. The PTSD does contribute to the extent reflected by the currently assigned 50 percent rating. However, the combined effect of the service-connected disabilities does not render the Veteran unable to secure and follow a substantially gainful occupation. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. ORDER Entitlement to an initial disability rating for PTSD in excess of 50 percent is denied. Entitlement to a TDIU is denied. ____________________________________________ T. D. JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs