Citation Nr: 1306027 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 12-18 326 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for a bilateral hearing loss disability. 2. Entitlement to disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD J.A. Flynn, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from November 1966 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, that denied the benefits sought on appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran's bilateral hearing loss disability is manifested by no worse than level V hearing acuity in the left ear and level II hearing acuity in the right ear. 2. The Veteran's PTSD is manifested by symptoms producing no more than occupational and social impairment with reduced reliability and productivity due to impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. 3. The Veteran's service-connected disabilities do not preclude him from securing and following a substantially gainful occupation consistent with his education and work experience. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for a bilateral hearing loss disability have not been met. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.85, 4.86, 4.87, Diagnostic Code 6100 (2012). 2. The criteria for an initial rating in excess of 50 percent for PTSD have not been met. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a TDIU have not been met. See 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.16, 4.18 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veterans Claims Assistance Act of 2000 (VCAA) The Board has given consideration to the VCAA, which includes an enhanced duty on the part of VA to notify a veteran as to the information and evidence necessary to substantiate claims for VA benefits. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). The VCAA also redefines the obligations of VA with respect to its duty to assist veterans in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012). Upon receipt of a substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence that (1) is necessary to substantiate the claim; (2) VA will seek to provide; and (3) the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). A February 2012 letter informed the Veteran of all of these elements. The Board concludes that VCAA notice requirements have been satisfied with respect to the issues on appeal. VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Service treatment records have been associated with the claims file. All identified and available treatment records have been secured, which includes VA treatment records and examination reports, private treatment records, and records from the Social Security Administration (SSA). The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not reflect the current state of the Veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In the instant case, the Veteran was provided with VA examinations of his conditions in March 2012. The examination reports indicate that the examiners recorded the Veteran's current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these examination reports are adequate for the purpose of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Specifically with respect to audiological examinations, in Martinak v. Nicholson, 21 Vet. App. 447 (2007), the United States Court of Appeals for Veterans Claims (Court) noted that VA revised its hearing examination worksheets to include the effect of the veteran's hearing loss disability on occupational functioning and daily activities. See Revised Disability Examination Worksheets, Fast Letter 07-10 (Dep't of Veterans Affairs Apr. 24, 2007); see also 38 C.F.R. § 4.10 (2012). The Court also noted that even if an audiologist's description of the functional effects of the Veteran's hearing disability was somehow deficient, the Veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. Neither the Veteran nor his representative has asserted that there is any deficiency in the examination conducted. Further, the Board notes that the VA examination report discussed the Veteran's problems with difficulty understanding speech, especially in crowded environments. Thus, as contemplated by Martinak and directed by 38 C.F.R. § 4.10, the examiner discussed the functional effects of the Veteran's hearing problems in the examination report. The Board acknowledges that ordinarily, the present level of disability is of primary concern when entitlement to compensation has already been established and an increase in the disability rating is at issue. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). While a new VA examination is not warranted based solely upon the passage of time, VA's duty to assist includes providing a new medical examination when a veteran asserts or provides evidence that a disability has worsened and the available evidence is too old for an adequate evaluation of the current disability. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007); Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that the Board should have ordered a contemporaneous examination of the veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating). In the instant case, in April 2012, after his March 2012 examinations, the Veteran stated that all of his conditions had worsened. In December 2012, however, the Veteran's representative submitted a motion to advance the Veteran's case on the docket due to life-threatening illness. This motion was accompanied by medical evidence indicating that the Veteran had suffered a severe subdural hematoma in July 2012. Medical records from November 2012 indicate that the Veteran had met his "maximum potential" and was on custodial care. The Veteran was able to open his eyes when spoken to and squeeze the clinician's hand, but the was not able to follow any other commands. The Board has received no evidence suggesting that the Veteran has recovered from this state. Therefore, while the Board acknowledges that the Veteran contended that his condition had worsened, it additionally finds, unfortunately, that given the Veteran's non-communicative state, additional VA examinations addressing the Veteran's hearing loss and PTSD would not serve a purpose at this time. In June 2012, the Veteran requested a videoconference hearing before a Veterans Law Judge. A videoconference hearing was scheduled for November 2012. The Veteran failed to appear for that hearing, apparently as a result of the above-discussed health crisis. A postponement was neither requested nor granted. The Veteran has not requested that the hearing be re-scheduled. Under these circumstances, VA considers the hearing request to have been withdrawn. See 38 C.F.R. § 20.704 (2012). The Board observes that all due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). Accordingly, the Board will proceed to a decision. Principles of Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2012). When 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 (2012). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2012); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. See 38 C.F.R. § 4.14 (2012). Increased Rating for a Bilateral Hearing Loss Disability The Veteran contends that his bilateral hearing loss disability is worse than the current 10 percent evaluation. Disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Bruce v. West, 11 Vet. App. 405, 409 (1998) (quoting Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992)). The regulations set forth eleven auditory acuity levels, designated from Roman numerals I to XI, in escalating order of hearing impairment. See 38 C.F.R. § 4.85 (2012). The appropriate auditory acuity level is determined based on a combination of the percent of speech discrimination and the puretone threshold average. When an audiologist certifies that use of the speech discrimination test is not appropriate, then Table VIa, "Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average," is used alone to determine the auditory acuity level. In exceptional cases in which the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, Table VI or Table VIa is to be used, whichever results in the higher numeral. See 38 C.F.R. § 4.86(a) (2012). Similarly, when the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, Table VI or Table VIa is to be used, whichever results in the higher numeral. Thereafter, that numeral will be elevated to the next higher numeral. See 38 C.F.R. § 4.86(b) (2012). Once an acuity level is established for each ear, Table VII, "Percentage Evaluations for Hearing Impairment" is used to determine the appropriate disability evaluation. The appropriate evaluation is determined based on a combination of the levels of hearing impairment established for each ear. Turning to the facts in the instant case, in a March 2012 audiological examination, the following puretone results were noted (in decibels): HERTZ 1000 2000 3000 4000 LEFT 25 70 75 80 RIGHT 30 55 80 85 Puretone threshold averages were 62 decibels in the both ears. Speech discrimination scores were 100 percent and 94 percent in the left and right ears, respectively. Turning now to a determination of the level of hearing acuity in each ear, this audiometric evaluation demonstrates that the Veteran had level II hearing in both ears (between 58 and 65 average puretone decibel hearing loss, with between 92 and 100 percent speech discrimination). With an acuity level determined for each ear, the Board turns to Table VII in order to determine the appropriate percentage evaluation for the Veteran's level of hearing acuity. With both the poorer and better ear at level II hearing loss, a 0 percent (noncompensable) rating is warranted under Diagnostic Code 6100. See 38 C.F.R. § 4.85 (2012). The Board has also considered, however, the provisions of 38 C.F.R. § 4.86 governing exceptional patterns of hearing impairment. The Veteran's left ear has an exceptional pattern of hearing loss because the above audiogram demonstrates a reading of fewer than 30 decibels at 1000 Hertz and 70 decibels at 2000 Hertz. See 38 C.F.R. § 4.86(b) (2012). When an exceptional pattern of hearing loss exists, VA is to use the higher level of Tables VI and VIa. As noted above, Table VI indicates that the Veteran has level II hearing loss in his left ear. Table VIa indicates that the Veteran has level IV hearing loss in his left ear (between 56 and 62 average puretone decibel hearing loss). Elevating that level to the next highest level results in level V hearing loss in the left ear. The Veteran's right ear does not demonstrate an exceptional pattern of hearing loss. While the puretone threshold is 30 decibels at 1000 Hertz, it is not 70 decibels or more at 2000 Hertz. Similarly, the puretone threshold at each of the four specified frequencies is not 55 decibels or greater. See 38 C.F.R. § 4.86(a) (2012). Entering these numeric designations into Table VII, with the poorer ear at level V hearing loss and the better ear at level II hearing loss, a 10 percent rating is warranted under Diagnostic Code 6100. See 38 C.F.R. § 4.85 (2012). To the extent that the Veteran contends that his hearing loss is more severe than the current 10 percent evaluation, the Board observes that the Veteran is competent to report symptoms such as difficulty hearing soft voices, high frequencies, and difficulty discriminating during conversations. See Layno v. Brown, 6 Vet. App. 465, 467-69 (1994) (stating that the veteran as a lay person is competent to report information of which he has personal knowledge, that is, information that he can gather through his senses.) Despite the competence of the Veteran's observation, a higher schedular rating for hearing loss requires not only a description of symptoms, but greater objectively-measured levels of hearing loss. In short, the Board concludes that the preponderance of the evidence is against granting an increased evaluation for the Veteran's service-connected bilateral hearing loss disability. The Board further finds that there have been no distinct periods of time during which the Veteran's disability was compensable. He is accordingly not entitled to receive a "staged" rating. See Hart. Increased Rating for PTSD The Veteran contends that he is entitled to a disability rating in excess of 50 percent for his PTSD. Under the general rating formula used to rate psychiatric disabilities other than eating disorders, the relevant criteria are as follows: A 50 percent rating is appropriate 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; disturbances of motivation and mood; and difficulty establishing effective work and social relationships. A 70 percent rating is appropriate 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 that 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 an inability to establish and maintain effective relationships. A 100 percent rating is appropriate 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; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency must assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment, but it cannot assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). The Board notes that the specified factors for each incremental rating are examples-rather than requirements-for a particular rating, and the Board will not limit its analysis solely to whether the Veteran exhibited the symptoms listed in the rating scheme. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Also relevant to the Board's analysis is the Global Assessment of Functioning (GAF) assigned to the Veteran, which is a scale that reflects 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 Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). While the Veteran's GAF score is not itself determinative of the most appropriate disability rating, the Board must consider it when evaluating the appropriate disability rating for the Veteran. See VAOPGCPREC 10-95. A description of the relevant GAF range is as follows: GAF scores ranging from 61 to 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, has some meaningful interpersonal relationships. DSM-IV, pp. 46-47. See 38 C.F.R. § 4.130 (2012) (incorporating by reference the provisions of the DSM-IV for rating purposes.) Turning to the facts in the instant case, in March 2011, a VA clinician noted that the Veteran complained of nightmares, intrusive thoughts, irritability, insomnia, social avoidance, and emotional numbing. The Veteran indicated that he coped with anxiety primarily though social withdrawal and avoidance of stimuli that evoked memories of his military service. The Veteran's affect was depressed, anxious, and tense. The Veteran was neat and clean in appearance, and his behavior was cooperative and calm. The Veteran's thought process was logical and goal-directed, and his thought content was congruent with reality. The Veteran's speech was of a normal rate, volume, and tone, and the Veteran was oriented to person, place, and time. The Veteran had no hallucinations. The Veteran's memory and attention span were within normal limits, and his insight and judgment were good. The Veteran had no suicidal or homicidal ideation. In June 2011, a VA clinician noted that the Veteran stated that he stayed away from people, but he tried to remain close with his sons and grandsons. The Veteran's affect was depressed, anxious, and tense. The Veteran was neat and clean in appearance, and his behavior was cooperative and anxious. The Veteran's thought process was logical and goal-directed, and his thought content was congruent with reality. The Veteran's speech was of a normal rate, volume, and tone, and the Veteran was oriented to person, place, and time. The Veteran had no hallucinations. The Veteran's memory and attention span were within normal limits, and his insight and judgment were good. The Veteran had no suicidal or homicidal ideation. In September 2011, a VA clinician noted that the Veteran complained of sleep disturbance, restlessness during sleep, intrusive thoughts, fear of darkness, irritability, hyperarousal, hyper-reactivity, a proclivity towards interpersonal anger and conflict, and avoidance of memories about the war. The Veteran reported drinking alcohol more frequently. The Veteran reported that he had lived alone for the past 30 years. The Veteran's affect was depressed, anxious, and tense. The Veteran was neat and clean in appearance, and his behavior was cooperative and anxious. The Veteran's thought process was logical and goal-directed, and his thought content was congruent with reality. The Veteran's speech was of a normal rate, volume, and tone, and the Veteran was oriented to person, place, and time. The Veteran had no hallucinations. The Veteran's memory and attention span were within normal limits, and his insight and judgment were good. The Veteran had no suicidal or homicidal ideation. In January 2012, a VA clinician indicated that the Veteran reported decreasing his use of alcohol for health reasons. The Veteran reporting having a continuing close relationship with his grandchildren. The Veteran reported living alone but having a strong social support group. The Veteran was appropriately groomed, and his affect was depressed, anxious, and tense. The Veteran was cooperative, but depressed. The Veteran's thought process was logical and goal-directed, and his thought content was congruent with reality. The Veteran's speech had a normal rate, volume, and tone. The Veteran was oriented to person, place, and time. The Veteran had no hallucinations. The Veteran's memory and attention span were within normal limits, his insight and judgment were good. The Veteran had no suicidal or homicidal ideation. The Veteran received a VA examination in March 2012. The Veteran reported that he had not had any significant romantic relationships since his last evaluation in 2007. The Veteran reported having three sons and one daughter. The Veteran indicated that he maintained relationships with his children, and he reported that they were supportive of him. The Veteran had five grandchildren, one of whom he saw frequently because the child lived in the same town as he did. The Veteran reported enjoying taking his grandchildren to the park or watching baseball with them. The Veteran reported that he maintained relationships with his siblings, and he reported that he had good friends that he saw routinely. The Veteran indicated that he spent a typical day working in his garden or in his garage, and he indicated that he spent time at the American Legion. The Veteran's activities of daily living were intact. The Veteran could independently dress, bathe, and groom himself, and he could manage his own housekeeping. The Veteran could drive and manage his own medications. The Veteran reported drinking three to four days per week, four to five beers at a time, but the Veteran did not drink to the point of experiencing intoxication or blackouts. The Veteran did not use illicit drugs. The Veteran reported experiencing no ill health effects as a result of his drug or alcohol use. The Veteran had not been hospitalized for any psychiatric treatment since the time of his 2007 evaluation. The Veteran underwent continuing group therapy, and the Veteran reported that these groups were helpful in reducing his symptoms. The Veteran reported having no homicidal or suicidal ideation, plan, or intent. The Veteran did not report any problems relating to anger, aggression, or impulsivity. The Veteran described his current mood as "all right," and he did not report feeling sad or down. The Veteran did not report a decline in interest in activities, social isolation, or withdrawal. The Veteran had no problems relating to his appetite. The Veteran indicated that he slept six to seven hours nightly and felt rested in the morning. The Veteran indicated that his energy level during the day was good. The Veteran did not describe experiencing symptoms of worthlessness or guilt, and he reported no problems associated with concentration or memory. The Veteran indicated that noises continued to bother him at night, and he continued to feel irritability and hypervigilance. The examiner observed no symptoms of generalized anxiety, panic, mania, psychosis, or obsessive-compulsive behavior. The Veteran arrived on time for his examination, and he was appropriately groomed and casually dressed. The Veteran appeared his stated age. The Veteran's gait was unremarkable and his ambulation was independent. The Veteran's manner was cooperative and his eye contact was appropriate. The Veteran's speech was unremarkable. The Veteran's thought processes were logical and goal-directed, and there was no evidence of hallucinations or delusions. The Veteran's mood was euthymic and his affect was mood-congruent. The Veteran was oriented to person, place, date, and situation. The Veteran's concentration was not impaired, his fund of information was good, and his immediate retention was good. The Veteran's memory, judgment, and insight were all good. The examiner indicated that the symptoms associated with the Veteran's PTSD had significantly improved since the time of his last examination. The examiner concluded that the Veteran had good functioning in all areas. The Veteran maintained stable social and interpersonal relationships. The examiner assigned the Veteran with a GAF score of 70. An April 2012 VA treatment record indicated that the Veteran reported symptoms of hyperarousal, intrusive thoughts, impulse control problems, and avoidance of certain stimuli. The Veteran denied suicidal ideation, suicide attempts, or substance abuse. The Veteran reported that family relations were very important to him, and he was close to his grandson. The Veteran reported that he lived alone at home. The Veteran was appropriately groomed, and his affect was depressed, anxious, blunt, and tense. The Veteran's behavior was cooperative, anxious, and depressed. The Veteran's thought process was logical and goal-directed, and his thought content was congruent with reality. The Veteran's speech was of a normal rate, volume, and tone. The Veteran was oriented to person, place, and time. The Veteran had no hallucinations, and his memory and attention span were within normal limits. The Veteran's insight and judgment were good. The clinician observed that the Veteran had a supportive social network of friends and family. The Board has also reviewed records from the Veteran's VA group psychotherapy sessions, which generally indicate that the Veteran participated fully, shared openly, and used the sessions fully. After a thorough review of the evidence, the Board finds that the totality of the evidence indicates that the impact of the Veteran's PTSD on his social and industrial functioning is most congruent with the currently-assigned 50 percent evaluation. Although the Veteran does not have all the symptomatology consistent with the assignment of a 50 percent rating, the Board finds that the impact of the Veteran's anxiety disorder on his social and occupational functioning sufficiently approximates the degree of impairment contemplated by a 50 percent rating. See 38 C.F.R. § 4.7 (2012). The Board acknowledges that the record contains evidence of certain elements of a 70 percent rating, but concludes that the Veteran's overall disability picture is not most congruent with a 70 percent rating. As noted above, a 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. While the Board observes that the Veteran has been unemployed throughout the period on appeal, as will be discussed in further detail in the TDIU discussion below, the Board observes little evidence of record supporting the Veteran's contention that his PTSD rendered him incapable of obtaining or maintaining employment. Additionally, while the Board is mindful of the guidance from Mauerhan that the symptoms listed in the General Rating Formula for Mental Disorders are not meant to be used as an exhaustive list, the Board observes that the Veteran has met or approximated only one of these listed symptoms: the Veteran's PTSD arguably causes him to experience difficulty adapting to a work-like setting. The Veteran has not demonstrated suicidal ideation, obsessional rituals, illogical, obscure, or irrelevant speech, near-continuous panic or depression, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, and an inability to establish and maintain effective relationships. Indeed, while the Veteran has reported engaging in isolative behavior as a result of his PTSD, he indicated a number of times how much he valued his close relationships with his siblings, children, and grandchildren. For these reasons, the Board finds that while the record arguably contains a few symptoms associated with a 70 percent rating, a 70 percent rating of the Veteran's PTSD is not appropriate in the instant case. Similarly, for the reasons stated above, the Board concludes that the Veteran's overall disability picture is not most congruent with a 100 percent rating during this time. As noted above, a 100 percent disability rating contemplates "total occupational and social impairment." The Veteran does not present a persistent danger of hurting himself or others. The record shows no evidence of gross impairment in thought processes or communication, persistent delusions or hallucinations, or grossly inappropriate behavior. The Veteran has not shown an intermittent inability to perform activities of daily living, disorientation to time and place, or memory loss for the names of close relatives, his own occupation, or his own name. The Veteran stated on a number of occasions how important it was to him to continue to maintain good relationships with his children and grandchildren. For these reasons, the Board finds that, a 100 percent rating of the Veteran's PTSD is not appropriate in the instant case. In making this determination, the Veteran's GAF scores of record have been considered. During the appeal period, the Veteran was assigned a GAF score of 70 in his March 2012 VA examination. The Board finds that this score, which is indicative of "mild" symptoms, was based on a thorough examination of the Veteran and is similarly inconsistent with a greater disability rating in the instant case. In light of the foregoing, the Board concludes that while the Veteran demonstrates a few symptoms associated with a higher disability rating, the evidence of record does not show that the overall level of severity more closely approximates the criteria for a 70 percent or 100 percent disability rating than a 50 percent rating. See 38 C.F.R. § 4.130 (2012). While acknowledging that the Veteran is impaired by his PTSD in his social and occupational spheres, the facts nevertheless establish that for the time period at issue, the Veteran was not isolated and estranged from the community at large. Moreover, there are no other factors that would lead the Board to conclude that a 70 percent or 100 percent disability rating is warranted. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (noting that the specified factors for each incremental rating are examples rather than requirements for a particular rating; analysis should not be limited solely to whether the veteran exhibited the symptoms listed in the rating scheme.) A review of the medical evidence indicates that the Veteran's psychiatric symptomatology centers on his depression, anxiety, irritability, nightmares, disturbances of mood and motivation, and difficulty establishing work and social relationships. These symptoms are most congruent with the assigned 50 percent disability rating. Consideration has also been give to the Veteran's personal assertions in support of his claim. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as feelings of stress, anxiety, and depression. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a)(2) . However, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of his psychiatric disability in terms of the applicable rating criteria and its effect on his ability to work. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Rather, this necessarily requires appropriate medical findings regarding the extent and nature of his psychiatric disorder. The clinical evidence of record does not indicate that the assignment of any increased evaluation is warranted. There is also no basis for a staged rating of the Veteran's PTSD because the Veteran's disability picture is essentially uniform throughout the appeal period. See Fenderson. Extra-Schedular Considerations In addition, the Board has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In Thun v. Peake, the Court set forth a three-step inquiry to determine a veteran's entitlement to an extra-schedular rating. See 22 Vet. App. 111 (2008). First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. In this case, it is not necessary to go any further than the first step of the Thun analysis. The rating criteria are not inadequate, and it does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluations for his level of impairment. In other words, he does not have any symptoms from his service-connected disorders that are unusual or are different from those contemplated by the schedular criteria. The Board notes that while the Veteran may have difficulty hearing in a noisy environment, the hearing loss in his left ear has been rated based on an exceptional pattern of hearing impairment. See Martinak v. Nicholson, supra. The available schedular evaluations for the service-connected disabilities are adequate. Referral for extra-schedular consideration is not warranted. Further inquiry into extra-schedular consideration is moot. See Thun. TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a veteran is precluded, by reason of service-connected disability, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. See 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disability or disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. Under 38 C.F.R. § 4.16, if, as in the instant case, there are two or more such disabilities, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a) (2012). When these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability, and consideration is given to the veteran's background including his employment and educational history. See 38 C.F.R. § 4.16(b) (2012). The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. See Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). In the instant case, the Veteran is service connected for: (i) PTSD, which is evaluated as 50 percent disabling, (ii) tinnitus, which is evaluated as 10 percent disabling, and (iii) bilateral hearing loss, which is evaluated as 10 percent disabling. The Veteran's combined disability rating is 60 percent. 38 C.F.R. § 4.25 (2012). The Veteran's service-connected disabilities do not meet the percentage rating standards for the award of a schedular TDIU. See 38 C.F.R. § 4.16(a) (2012). Nonetheless, the Board must consider whether the evidence warrants referral to the appropriate VA officials for entitlement to a total disability rating for compensation purposes based on individual unemployability on an extraschedular basis under the provisions of 38 C.F.R. § 4.16(b). See Bowling, 15 Vet. App. at 6. For a veteran to prevail on a claim of entitlement to TDIU, the record must reflect some factor that takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough; the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). Having reviewed the record, the Board finds no evidence suggesting that the Veteran's case is outside the norm, requiring extraschedular consideration. The Veteran has complained that his PTSD symptoms prevent his from gaining and maintaining employment. The Board finds, however, that the medical evidence does not support the Veteran's claim. During his March 2012 examination, the Veteran indicated that he had been laid off approximately a year and a half before the examination. Before that, he had been employed as a millwright for over 38 years. After an examination of the Veteran, the examiner concluded that there was no psychiatric reason that would preclude the Veteran from working. Similarly, the Veteran's March 2012 audiological examiner concluded that the Veteran's hearing loss and tinnitus did not impact his ability to work, instead noting that the Veteran "should not" have difficulty seeking gainful employment given his current symptoms. The examiner found that in a quiet situation where the speaker directly faced him, he could communicate with ease. Further, the evidence includes information from the Veteran's most recent employer. The employer indicated that the Veteran did not require any accommodations or miss any work due to his service-connected disabilities, and the Veteran stopped working as a result of a lack of work. While the Board does not doubt that the Veteran's service-connected disabilities have some effect on his employability, as evidenced by his 60 percent combined disability rating, the weight of the evidence does not support his contention that his service-connected disabilities are of such severity so as to preclude his participation in any form of substantially gainful employment. The Board believes that the symptomatology associated with the service-connected disabilities are appropriately compensated by the currently-assigned 60 percent combined disability rating. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1 (2012). Indeed, 38 C.F.R. § 4.1 specifically states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Thus, the Board finds that the RO's decision not to refer this issue to the Director of Compensation and Pension Service for extraschedular consideration of a TDIU was correct. As such, the benefit of the doubt doctrine is inapplicable, and the claim for TDIU must be denied. See 38 C.F.R. § 5107(b) (2011); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A rating in excess of 10 percent for a bilateral hearing loss disability is denied. A disability rating in excess of 50 percent for PTSD is denied. A TDIU is denied. _________________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeal