Citation Nr: 1301925 Decision Date: 01/17/13 Archive Date: 01/23/13 DOCKET NO. 10-39 955 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE 1. Entitlement to an initial compensable evaluation (rating) for adjustment disorder with depressed mood as secondary to the service-connected prostate cancer and erectile dysfunction disability. 2. Entitlement to a total disability compensation rating based on individual unemployability (TDIU). ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1968 to June 1971. This case comes to the Board of Veterans' Appeals (Board) on appeal of a January 2010 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Winston-Salem, North Carolina, which granted service connection for an adjustment disorder with depressed mood and assigned a 0 percent rating, effective May 19, 2009. The Board has determined that the issue of entitlement to a TDIU due to service-connected disabilities has been raised by the record part and parcel to his initial service connection claim for an adjustment disorder, and thus has considered the TDIU claim as on appeal as pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the Veteran also filed a formal TDIU claim in April 2010, which was adjudicated by the RO in a December 2011 supplemental statement of the case as part of the Veteran's claims on appeal. Therefore, the issues are correct as noted on the first page of this decision. FINDINGS OF FACT 1. The Veteran's adjustment disorder with depressed mood is manifested by at most mild occupational and social impairment that most nearly approximated an occasional decrease in work efficiency and ability to perform tasks during periods of significant stress due to symptoms such as depression, memory loss, and sleep impairment. 2. The Veteran's service-connected adjustment disorder with depressed mood and prostate cancer with radical prostatectomy and erectile dysfunction do not preclude him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a 10 percent evaluation, but not higher, for adjustment disorder with depressed mood have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code (DC) 9440 (2012). 2. The criteria for a total disability rating based on unemployability due to service-connected disabilities have not been met. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist 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, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist a Veteran 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, 3.326(a) (2012). This appeal arises from disagreement with the initial evaluation following the grant of service connection. The Veteran received notice of the evidence needed to substantiate his service connection claim in May 2009. The courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained service treatment records, VA treatment records, private medical examinations, and lay statements. Additionally, the Veteran was provided VA examinations in December 2009 and November 2011 to address his claim for adjustment disorder with depressed mood. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As set forth in greater detail below, the Board finds that the VA examinations obtained in this case are adequate as they are predicated on a review of the claims folder and medical records contain therein; contains a description of the history of the disability at issue; document and consider the Veteran's complaints and symptoms; fully address the relevant rating criteria; and contain a discussion of the effects of the Veteran's adjustment disorder with depressed mood on his occupational and daily activities. The opinions in 2011 also address the issue of employability as it pertains to both of the Veteran's service-connected disabilities. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claim, and to respond to VA notices. Importantly, the Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Therefore, the Board finds that there is no reason to believe that any possible outstanding records would contain information relating to the Veteran's claim. Disability Rating Criteria Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The schedular criteria, effective as of November 7, 1996, 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. A rating of 10 percent is warranted for a mental disorder 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. 38 C.F.R. § 4.130, DC 9440. A rating of 30 percent is warranted for a mental disorder 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). Id. 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. Id. 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. Id. A 100 percent schedular 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, DC 9440. 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 31-40 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 41-50 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)." Id. 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)." Id. 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." Id. A GAF score of 71-80 indicates that "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). The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue. The GAF score must be considered in light of the actual symptoms of a veteran's disorder, which provide the primary basis for the rating assigned. Richard, 9 Vet. App. 266, 267 (1996). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive. The Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran 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 U.S. Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F. 3d 1331, 1336-1337 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has reviewed all the evidence, lay and medical, especially in regard to the mental disorder symptoms and impairments that the Veteran is competent to report. See 38 U.S.C.A. § 7104(a) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran 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 shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F. 3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Initial Rating for Adjustment Disorder The Veteran was granted service connection and initially assigned a 0 percent (noncompensable) rating for adjustment disorder with depressed mood, effective May 19, 2009, in the January 2010 rating decision on appeal. The Board finds that, for the entire initial rating period, the Veteran's service-connected adjustment disorder has been characterized by mild symptoms of depression, memory loss, and sleep impairment. Such symptomatology is contemplated by the 10 percent criteria for rating adjustment disorder under DC 9440. See 38 C.F.R. § 4.130. In an April 2009 private psychological evaluation, the Veteran reported that as a result of his service-connected prostate cancer he suffers from depressed mood, loss of self-esteem, fatigue, diminished ability to think, and sleep problems. During the mental status examination, the licensed psychological associate, L.G., reported that the Veteran was cooperative, soft spoken, and normally dressed. The Veteran's mood was dysthymic, blunted affect, and he had limited range of emotion. No current suicidal or homicidal ideation was present. L.G. assigned a GAF score of 37 and stated that the Veteran's symptoms cause clinically significant impairment in his social, occupational, and personal functioning. It was noted that because of his problems with concentration and memory he was unable to learn new work tasks. His irritability and feelings of isolation severely limited his ability to initiate or sustain work relationships. It also was noted that because of his isolating behaviors and poor self-esteem, the Veteran is severely limited in his ability to initiate or sustain social relationships. L.G. concluded that the Veteran was "permanently and totally disabled and unemployable." In a follow-up evaluation in October 2009, L.G. again noted the assigned GAF score of 37 and stated the Veteran was sleep disturbed, very depressed, anxious, and unable to perform required tasks at work. L.G. opined that the Veteran was totally and permanently disabled and unemployable. The Board notes that a mental status examination and objective testing were not performed during the October 2009 sessison. In June 2009, the Veteran was examined by Dr. P.M. for a psychological evaluation. According to the doctor, the evaluation was a one-time visit, lasting two hours. Dr. P.M. did not review the evidence of record, but instead reported based on the Veteran's statements and provided a history of the Veteran's medical conditions and background. At the time of the evaluation, the Veteran was not taking medication for his mental disorder and was not involved in any treatment. On mental status examination, the Veteran was found to be pleasant and cooperative, oriented times three (time, place, person), without signs of psychosis, thought disorder, hallucinations, delusions, or paranoia. The Veteran was able to converse cogently and his memory seemed to function fairly well though with deficits. His mood was depressed, affect blunted, and his voice was quiet. The Veteran denied suicidal or homicidal ideation. The doctor reported that the Veteran was isolated and avoided being in social situations. It also was noted that the Veteran was quite anxious and said he got nervous and frigidity, also would get irritable easily. Dr. P.M. diagnosed the Veteran with major depression and assigned a GAF score of 50 and stated that the Veteran was so depressed that he was unable to work. The Veteran had a VA compensation examination in December 2009. The examiner noted the Veteran's history in detail and reviewed the evidence of record. The Veteran reported that his mood is "generally pretty good", although he did report a diminished interest in his favorite activities, including fishing and softball. The Veteran reported mild sleep impairment, weight gain, and feelings of guilt and worthlessness related to impotence. During the December 2009 examination, the Veteran was cooperative and attentive. He evidenced no significant impairment in his thought processes or communication ability. There was no significant impairment in short-term or long-term memory processes. He also evidenced no delusions, hallucinations, or inappropriate behavior. He denied episodes of panic attacks. He reported no suicidal or homicidal ideations. The examiner diagnosed the Veteran with chronic adjustment disorder with depressed mood and assigned a GAF score of 80. The examiner opined that the Veteran does not meet the DSM-IV criteria for a mood disorder. The Veteran was reporting mild symptoms of depression (mild sleep impairment, slight weight gain, feelings of guilt and worthlessness related to impotence) that appear to be related to his prostate removal. Moreover, after a review of the record, the examiner stated that the Veteran does not appear to be seeking regularly scheduled treatment for mood-related problems. Finally, the examiner opined that the Veteran's mental disorder symptoms were not severe enough to interfere with occupational and social functioning. The Veteran underwent a second VA examination in November 2011. The examiner provided a detailed history of the Veteran and reviewed the evidence of record. The examiner noted that the Veteran's symptoms were mild and did not meet the criteria for major depression. The examiner noted that the Veteran was not on antidepressant medications and attended only one therapy session. Importantly, unlike the other examinations mentioned above, the November 2011 examiner performed clinical objective findings. Specifically, the examiner administered the Wechsler Abbreviated Scale of Intelligence Test (WASI); the Wechsler Memory Scale-III-Abbreviated Test (WMS-IIIA); Trail Making Test A & B; Reitan-Indiana Aphasia Screening Test, Geriatric Depression Scale (GDS); and the Personality Assessment Inventory (PAI). The clinical findings showed that although the Veteran's scores were all within normal limits, they did include mild symptoms of depression. The examiner assigned a GAF score of 72 and concluded that "it is less likely than not" that the Veteran has a mental disorder impairing his social and occupational functioning. On review of all the evidence above, the Board finds that the December 2009 and November 2011 VA examination are of greatest probative value. According to the U.S. Court of Appeals for Veterans Claims, "the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches." Guerrieri v. Brown, 4 Vet. App. 467, 470 (1993). The credibility and weight to be attached to these opinions is within the province of the Board. Id. In this case, the Board finds that the December 2009 and November 2011 have provided more probative evidence in assessing the severity of the Veteran's adjustment disorder claim. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when VA gives an adequate statement of reasons and bases). Unlike in the examinations by L.G., Dr. P.M., the December 2009 and November 2011 VA examiners provided a well-reasoned rationale for assessing the severity of the Veteran's symptoms. Additionally, there are inconsistencies between the private examinations and the December 2009 and November 2011 VA examinations. For example, both Dr. P.M. and L.G. stated that the Veteran is isolated and avoids being in social situations. On the other hand, the December 2009 examiner noted that the Veteran described his relationships with his wife of 37 years and two adult children with one grandchild as "good." He also reported having a couple of good friends, with whom he associated, one of which drove him to the evaluation. He reported that he was involved in his church and attended church regularly in addition to a Bible study class. He indicated that he just met a good friend who fishes a lot and he was looking forward to some possible fishing trips. On the November 2011 examination, the examiner noted that the Veteran lives with his wife of 38 years and their adult son. The Veteran was noted to have an active role in his church and supportive relationships with his children. The examiner noted that the Veteran was planning to visit his granddaughter in Florida in a few months. These reports, many of which are from the Veteran, do not demonstrate social impairment, or social isolation. In addition while the private treatment records indicated that the Veteran was totally and permanently disabled as a result of his psychiatric disorder and could not work because of it, these professionals did not note that the other evidence shows the Veteran was laid off from his last employment and that he suffered an on-the-job injury to his back during his employment, which was noted as the reason he was no longer working. Also, unlike the private examinations by L.G. and Dr. P.M., the December 2009 and November 2011 VA examiners conducted a detailed review of the evidence of record and performed objective clinical testing instead of reporting solely on the Veteran's statements. Additionally, the November 2011 VA examination included objective psychometric testing as a basis of the Veteran's evaluation. While the private treatment providers relied on the Veteran's reported symptoms, as discussed in more detail below, the Board does not accept the credibility of his statements due to his inconsistencies. Therefore, any opinion that relies on the Veteran's reports also is not probative. For these reasons, the Board finds that the reports from Dr. P.M. and L.G. are of little probative value, and the Board has accorded more probative weight to the VA examinations. The Veteran contends that his mental disorder symptoms require a rating of either 70 percent or 100 percent. See Veteran's April 2010 statement. The Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing pain and weakness. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran has provided lay evidence with respect to his current symptoms and with respect to his work history. He is competent to provide such statements. Based on inconsistencies noted during the course of the private and VA examinations, the Board finds that the Veteran's lay statements as to the severity of his symptoms are not credible. For example, during the November 2011 VA examination, the Veteran reported that he was on both antidepressants and cholinesterase inhibitors for years; however, the VA examiner noted that corroborating records regarding antidepressant treatment indicate that the Veteran misreported his psychiatric treatment and has not had any. To the contrary, the evidence of record reflects that he has only attended mental health group counseling once in November 2011. Similarly, in the December 2009 VA examination, the Veteran stated that he was being seen by Dr. P.M. "every few months." This statement is inconsistent with Dr. P.M.'s letter which states that he only saw the Veteran one time in June 2009 and the Veteran did not follow up with further treatment. The Board finds that the Veteran's lay statements as to the severity of his adjusted mood and depression symptoms are not credible. Also, as noted above, even though the private treatment records indicate rather severe impairment associated with the Veteran's psychiatric disorder, the Board assigns little to no probative weight to these opinions, as they are not based on objective testing and are based on the Veteran's reported history, which the Board does not accept as credible. The VA examiners of record noted these private treatment records and still found that the Veteran did not exhibit any impairment as a result of his service-connected adjustment disorder with depressed mood. The record demonstrates that the Veteran's adjustment disorder is mostly characterized by mild symptoms of depression, memory loss, and sleep impairment. For the reasons mentioned above, the Board finds that a rating of 10 percent is warranted for an adjustment disorder with depressed mood because the probative evidence of record reflects that 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. See 38 C.F.R. § 4.130, DC 9440. The Board concludes, based on the competent, credible, and probative evidence of record, that the Veteran's adjustment disorder does not more nearly approximate the next-higher 30 percent rating criteria under DC 9440 for the entire initial rating period. Even though the Veteran exhibits depression, memory loss, and sleeping impairment, his disability picture does not demonstrate any significant occupational and social impairment. The Board resolves all doubt in the Veteran's favor that there is at least mild impairment due to his service-connected psychiatric disorder; however, the VA examiners in December 2009 and November 2011 specifically found that the Veteran's mental disorder did not impair his social and occupational functioning. Therefore, the next higher 30 percent rating is not warranted. See 38 C.F.R. § 4.7 (the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating, otherwise, the lower rating will be assigned.). In sum, the Board finds that the Veteran's adjustment disorder with depressed mood manifested by depression, memory loss, and sleep impairment do not meet the criteria for an initial rating higher than 10 percent disabling. The Board further finds that, during this appeal period, there were no distinct periods of time during which the Veteran's disability was more than 10 percent disabling. He is accordingly not entitled to receive a "staged" rating. Fenderson, 12 Vet. App. 119. Extraschedular Consideration The Board has considered whether referral for extraschedular evaluations are warranted for the Veteran's prostate cancer and adjustment disorder disabilities. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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 Veteran'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 a veteran's disability level and symptomatology, then the veteran'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 a veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the veteran'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) (stating that related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the Rating Schedule is inadequate to evaluate a veteran'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. 38 C.F.R. 3.321(b)(1). Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's adjustment disorder is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9440, 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 adjustment disorder has manifested depression, memory loss, and sleep impairment. These symptoms are part of the schedular rating criteria. The GAF scores are also incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. All of 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 PTSD, 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). TDIU The record contains some evidence suggesting the Veteran may be unemployable due to his service-connected disabilities. For example, the private opinions from Dr. P.M. and L.G. opined that the Veteran's mental disorder renders him unemployable. The Veteran also claims that his employer terminated him due to complications with his prostate cancer. See Veteran's November 2006 statement. Such evidence in the record suggesting unemployability constitutes an informal claim for TDIU. Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2012) that an informal claim identify the benefit sought has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (VA to determine all potential claims raised by the evidence, applying all relevant laws and regulations). See also Rice v. Shinseki, 22 Vet. App. 447 (2009) (suggesting, in an effective date appeal, that an appeal for higher rating somehow includes TDIU, or that a TDIU must arise from an increased rating claim, unless it is the veteran who raises the TDIU claim). Based upon the foregoing, the Board finds that the evidence of record has raised a claim of entitlement to TDIU Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total if it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of (1) a single service-connected disability ratable at 60 percent or more, or (2) as a result of two or more 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. See 38 C.F.R. §§ 3.340, 3.34l, 4.16(a). For the purpose of one 60 percent or one 40 percent disability in combination, disabilities resulting from a common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16(a)(2). Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by non-service- connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In this case, service connection currently is in effect for prostate cancer with radical prostatectomy and erectile dysfunction, evaluated as 60 percent disabling, and adjustment disorder with depressed mood as secondary to the service-connected prostate cancer and erectile dysfunction, evaluated as 10 percent (per this decision). The Veteran has a combined disability rating of 60 percent for the entire rating period. 38 C.F.R. §§ 4.16(a), 4.25. Thus, the combined schedular rating criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) are met because the Veteran has one disability rated at 60 percent. Consequently, the Board must determine whether the Veteran's service-connected disability precludes him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). This is so because a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Id. An inability to work due to advancing age may not be considered. 38 C.F.R. §§ 3.341(a), 4.19. In making its determination, VA considers such factors as the extent of the service-connected disability, and employment and educational background. See 38 C.F.R. §§ 3.340 , 3.341, 4.16, 4.19. In this case, the evidence of record fails to show that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected adjustment disorder and prostate cancer disabilities. While the private medical opinions from Dr. P.M. and L.G. opined that the Veteran's mental disorder alone renders him unemployable, the Board has found that these reports are of little probative value, as discussed in greater detail above. Further, no other clinician or professional has indicated that the Veteran is unemployable due to his service-connected disabilities. Notably, while the January 2007 VA genitourinary examination did not provide an opinion as to whether the prostate cancer affects the Veteran's occupational and daily activities, a November 2011 VA genitourinary examination report noted that the Veteran's service-connected disability of prostate cancer and its complications due to prostatectomy for treatment of prostate cancer had no impact on either physical or sedentary employment. The November 2011 VA psychiatric evaluation also determined that the Veteran's reported mental symptoms did not preclude active or sedentary employment. Other medical evidence of record indicates that the Veteran stopped working after an on-the-job back injury and continued to not work due to his back, which is not a service-connected disability. An October 2006 letter he submitted from his former employer notes that the Veteran was laid off due to business conditions. The Veteran submitted a statement along with this letter that the actual reason was that he had physical limitations due to his prostate cancer, but this is not corroborated by the letter from his employer. The December 2009 VA examination report also noted that the Veteran was injured on the job and continued to have back pain, which prevented him from doing the lifting and moving necessary in his chosen occupation. In addition, the November 2011 VA examiner report notes that the Veteran reported unemployment due to back problems on an initial mental health visit in April 2009. It was noted that he worked first as a mechanic and was promoted to truck repair division, and then he was on a forklift for the remainder of his career. He was laid off in 2006 for approximately six months and resumed work until 2009 when he stopped working due to disability related to an injury to his lumbar spine. The Veteran also reported that he was let go from his position in 2005 because they were putting more and more responsibility and duties on him and they wanted him to do more, and he told them "where they could put their job." Again, the examiner in November 2011 went on to find after administering objective testing that the Veteran's reported mental symptoms did not preclude active or sedentary employment. A separate November 2011 genitourinary examination report also made a similar finding with respect to the Veteran's prostate cancer and its complications due to prostatectomy for treatment of prostate cancer and the fact that there was no impact on either physical or sedentary employment. In consideration of the evidence of record, the Board finds that the Veteran's service-connected disabilities do not preclude him from securing and following a substantially gainful occupation. The Veteran has a history of working in manual labor type positions. The two VA examiners who addressed the matter determined that the Veteran was not precluded from active or sedentary employment as a result of his service-connected adjustment disorder with depressed mood and prostate cancer with residuals. The findings reported by the private treatment providers that the Veteran's mental disorder rendered him unemployable is not supported by the medical evidence of record and objective testing administered by the VA examiners. The Veteran's statement that he was terminated in 2006 due to his prostate cancer also is not supported by the other evidence of record, including the Veteran's own statements. The evidence rather shows that the Veteran has not been working due to factors other than his service-connected disabilities, specifically an injury to his back. Thus, in conjunction with medical problems including a low back condition, the Veteran's employability may be further impaired. However, nonservice-connected disabilities are not for consideration in this analysis. To the extent the adjustment disorder with depressed mood and prostate cancer affects the Veteran's employment, the assigned schedular ratings for the disabilities compensate the Veteran for such impairment. Thus, the assignment of a TDIU rating is not warranted. See 38 C.F.R. § 4.16(a). 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 Veteran's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A 10 percent initial rating, but not higher, for adjustment disorder with depressed mood as secondary to the service-connected prostate cancer and erectile dysfunction is granted. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. _________________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs