Citation Nr: 1309017 Decision Date: 03/18/13 Archive Date: 03/25/13 DOCKET NO. 10-22 292 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating for compensation purposes based on unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD D. Bredehorst INTRODUCTION The Veteran served on active duty from January 1966 to January 1968. These matters come before the Board on appeal from a June 2009 rating decision by the St. Louis that, in part, granted service connection for PTSD rated 30 percent disabling effective July 25, 2008, and denied a TDIU. The Board has reviewed the contents of the Veteran's electronic ("Virtual VA") file and found additional medical evidence pertinent to this appeal that is not in his claims file but that has been considered by the RO. Additional pertinent evidence was received in support of the Veteran's claims after the September 2012 supplemental statement of the case (SSOC) was issued and initial consideration by the RO was waived. The Veteran has claimed entitlement to an increased rating for ischemic heart disease and service connection for neuropathy of the bilateral upper extremities. See VA Forms, dated July 17, 2012. THESE MATTERS ARE REFERRED TO THE RO FOR APPROPRIATE ACTION. FINDINGS OF FACT 1. Throughout the appeal, the Veteran's PTSD is manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. The Veteran's service-connected PTSD is so severe as to preclude all substantially gainful employment consistent with his education and occupational background. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent rating, but not higher, for service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code (Code) 9411 (2012). 2. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1115, 5107 (West 2002); 38 C.F.R. § 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA applies to the instant claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative 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 VCAA notice 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. 38 C.F.R. § 3.159(b)(1) (including as amended effective May 30, 2008, 73 Fed. Reg. 23353 (Apr. 30, 2008)). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). As the June 2009 rating decision on appeal granted service connection for PTSD, and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). A March 2010 SOC provided notice on the "downstream" issue of entitlement to an increased rating. A September 2012 supplemental SOC (SSOC) readjudicated the matter after further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has had ample opportunity to respond/supplement the record, and is not prejudiced by any technical notice deficiency (including in timing) that may have occurred earlier in the process. He has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (holding that "where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). Regarding the TDIU claim, the decision below represents a complete grant of the benefit sought on appeal with regard to that issue. Thus, any deficiency in VA's compliance with the duty to notify and assist is nonprejudicial and any further discussion of VA's duties is not necessary. The Veteran's pertinent treatment records have been secured. Medical records from the Social Security Administration (SSA) were sought since the Veteran received disability benefits, but the RO was informed that those records are no longer available. See June and September 2011 SSA responses. The RO arranged for VA examinations in February 2009 and April 2012 that are deemed to be adequate for rating purposes. See Barr v. Nicholson, 21. Vet. App. 303 (2007); see Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Thus, VA's duty is met. Legal Criteria and Analysis for a Higher Initial Rating for PTSD 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 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2011). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7 (2012). Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. In this regard, the Board notes that when, after careful consideration of all the procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. The Veteran contends that his service-connected PTSD is more disabling than reflected in the current 30 percent rating. The disability is rated in according to the General Rating Formula for Mental Disorders (General Formula). According to the General Formula, a 30 percent disability rating is assigned where 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; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is 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 in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned when the psychiatric condition produces 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. A 100 percent rating is assigned when there is total occupational or 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; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9411. The symptoms contemplated by the regulatory criteria are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence establishes that the Veteran experiences other symptoms that cause occupational or social impairment equivalent to that which would be caused by the symptoms noted above, the appropriate equivalent evaluation is to be assigned. Id. at 443; see also Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004) (embracing the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities). The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Under DSM-IV, a GAF score of 41-50 generally reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational, of school functioning (e.g., no friends, unable to keep a job). A GAF score 51-60 generally reflects 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 coworkers). A score of 61-70 generally reflects 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. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). A July 2008 VA mental health record indicates the Veteran presented with symptoms of avoidance, poor self-concept, sleep difficulties, re-experiencing, secondary depression, relationship problems, hyperarousal, social isolation, shame, and guilt. July 2008 private treatment records note the Veteran's mood and affect were blunt, flat, and sad. His insight and judgment were intact, but he had poor recent memory recall. A July 2008 VA psychiatric note shows that the Veteran complained of sleeping problems, nightmares, persistent irritability, panic attacks, anxiety about personal safety, episodic depression, anger, memory problems, being easily startled, having unwanted bad memories about his Vietnam experience, and thoughts of dying. There was no history of hospitalization for emotional or mental problems. Although he had thoughts of dying, he denied having any plan or intent to act on the impulse to self-harm. The assessment for his risk of violence, assault on others, and legal problems was low. He had never been married but he maintained a relationship with the same woman for 38 years. There were no children as a product of this relationship. He described this relationship as great. The Veteran was not currently involved in any community projects or recreational activities/projects, and there were no personal hobbies that he enjoyed. An August 2008 VA psychiatric treatment record notes complaints of increased depression with decreased sleep, irritability and anger with poor sleep, flashbacks and lack of motivation and energy. He denied suicidal or homicidal ideation and hallucinations. At times he was afraid and scared to go into crowded places but he was not grossly psychotic. On mental status examination, his hygiene was fair as was his eye contact. He had decreased psychomotor activities and he was slow in thinking and in movement. He was cooperative and his speech was clear, coherent, and relevant but slow in tone and voice. His mood was depressed and his affect was blunted. He denied hallucinations and delusions. Insight, judgment, and impulse control were fair. His GAF score was 50. A December 2008 VA psychiatric record indicates the Veteran's depression improved with medication. He was better able to care for himself and he had less flashbacks. He was not a danger to self or others. On mental status examination, he was casually dressed and had fair hygiene and grooming. His speech was clear, coherent, and relevant. His mood was neutral and his affect was somewhat restricted. He denied suicidal and homicidal ideation and hallucinations. Insight, judgment, and impulse control were fair. His GAF score was 55. On February 2009 VA PTSD examination, the Veteran reported that he did not like to be in large crowds. He also complained of flashbacks, bad dreams that occurred approximately once a week, being easily startled, and a dislike for loud noises. He spent his days watching television and visiting with friends. He was a member of a veteran's organization but he only occasionally attended their meetings. There were no affiliations with any other clubs, groups, or organizations. Activities included doing some household and yard work. Occasionally he went out to dinner with his girlfriend and sometimes he drove her to the store. He liked to read and occasionally go deer hunting. He previously enjoyed pool tournaments but discontinued this activity due to back problems. On mental status examination, he was casually dressed and clean shaven. His speech was clear and his eye contact was good. At the outset of the interview he looked down toward the floor. His facial expression was somewhat flat, and his mood and affect were generally appropriate and congruent. He was oriented and had no difficulty with immediate recall tasks, but he only recalled two of three words on delayed recall. He successfully completed the attention, calculation, and language portions of the examination. There was n evidence of delusions or hallucinations, and he denied having current suicidal or homicidal thoughts. A GAF score of 55 was assigned. May 2009 VA treatment records show that he was depressed having to relive military experiences during his PTSD VA examination. His affect was very flat, dysphoric, and labile when recollecting Vietnam experiences. An increase in medication improved his PTSD and depression. On mental status examination he was casually dressed and had fair personal hygiene and grooming. His speech was clear, coherent, and relevant. His mood was neutral and his affect was appropriate. He denied suicidal and homicidal ideation, and hallucinations. Insight, judgment, and impulse control were fair. His GAF score was 55. An August 2009 VA psychiatric note indicates the Veteran continued to endorse depressed and sad feelings, and decreased motivation. The mental status examination showed that he was casually dressed and that his hygiene and grooming were fair. His speech was clear, coherent, and relevant, but his tone was soft and he was a bit upset and angry. His mood was sad and his affect was a little constricted. The Veteran denied suicidal or homicidal ideation and hallucinations. There was no evidence of paranoid ideation and his insight, judgment, and impulse control were fair. August and September 2009 statements from the Veteran's VA psychiatrist states that the Veteran is 50 percent disabled and that he is treated with medication and psychotherapy for PTSD and depression. The psychiatrist added that the Veteran still endorsed symptoms of sad mood, low energy, low self-esteem, blunted affect, poor concentration, decreased memory, social withdrawal, and poverty of speech. A September 2009 VA psychiatric notes indicates the Veteran reported that his depression was improved with a recent increase in medication. His affect was still blunted and he had flashbacks, but overall he was slightly improved. He did not have suicidal or homicidal ideation, feelings of hopelessness or helplessness, or hallucinations. The mental status examination showed that he was casually dressed, made fair eye contact, and had slow psychomotor activities. His speech was clear and relevant, but he talked with poverty of speech. His mood was sad and his affect was blunted. His judgment and impulse control were fair. His GAF score was 55. A December 2009 VA treatment record indicates the Veteran was casually dressed, made fair eye contact, and had speech that was clear and relevant. His mood was less sad and his affect was blunted. He denied homicidal thoughts and hallucinations. Insight and judgment were fair as was his impulse control. His GAF score was 56. An August 2010 VA psychiatric note located in the Veteran's Virtual file indicates that there were no changes in his condition. He reported going out to an event on July 4th, but he left early due to the fireworks. On mental status examination, he was casually dressed and he demonstrated good personal hygiene and grooming. His speech was clear, coherent, and relevant, and his mood was euthymic. He denied having suicidal or homicidal ideation and there was no evidence of hallucinations. His insight, judgment, and impulse control were fair. He was not a danger to self or others and he was cooperative. His GAF score was 60. A February 2011 VA psychiatric note located in the Virtual file indicates the Veteran reported having no significant changes. He had occasional nightmares with no change in frequency or severity. On mental status examination, he was casually dressed and he had good personal hygiene and grooming. His speech was clear, coherent, and relevant; his mood was euthymic with a congruent affect; and his insight, judgment, and impulse control were fair. He denied suicidal or homicidal ideation and hallucinations. His GAF score was 64. An October 2011 VA psychiatric note located in his Virtual file indicates the Veteran reported having increased nightmares, feelings of anxiousness mostly at night, tiredness, and irritability. He appeared unhappy, but he did not express and suicidal or homicidal ideation. He denied having flashbacks, but he indicated that he had nightmares 2 or 3 times a week. He was not a danger to self or others. On mental status examination, his speech was clear, relevant and logical; his mood was sad; and his affect was appropriate to his mood but it was somewhat constricted to blunt. He denied suicidal or homicidal ideation and hallucinations. His insight, judgment, and impulse control wee fair. The GAF score was 55. On April 2012 VA PTSD examination, the Veteran endorsed symptoms of anxiety, depression, anxiety attacks, flashbacks 2 to 3 times a year, nightmares 2 to 3 times a week, no desire to be around a large number of people as that made him nervous, and avoidance of large crowds. Loud noises or excessive noise made him feel anxiety and when he was anxious he became jittery and shaky. He was not currently receiving any treatment. He spent his time watching television, sitting on the porch, and watching sports. His girlfriend did all the house chores and he relied on others to do yard work. They rarely went out to eat and he rarely went shopping. He visited his girlfriend's sister and his brother, and kept in touch with his other siblings. He belonged to 4 organizations but only occasionally attended meetings at one of them. Occasionally, he listens to music, but he had no other hobbies or interests. The mental status examination showed that he was casually dressed, clean, and neat. His speech was clear and his thoughts were logical and coherent. The Veteran had poor eye contact and tended to divert his eyes to the left and toward the floor. His facial expression was flat and there was little modulation of emotion. His mood seemed depressed with a congruent affect. He appeared cooperative and agreeable. Memory testing indicated that there was no problem with immediate recall but there was some difficulty was delayed recall. No delusions or hallucinations were evident and there was no suicidal or homicidal ideation. He preferred to be alone and he isolated himself somewhat. The GAF score was 52. An April 2012 VA psychiatric note located in his Virtual file indicates the Veteran complained of episodic sadness, lack of motivation, and ongoing nightmares. He was very passive and calm during the interview. He was not considered a threat to self or others despite ongoing nightmares, sadness, and depression. On mental status examination, he was casually dressed; his speech was clear, relevant and logical; his mood was sad; affect was somewhat restricted; and insight and judgment were fair. He denied suicidal or homicidal ideation and psychosis. His GAF score was 58. A July 2012 VA psychiatric note located in his Virtual file indicates the Veteran reported having nightmares twice a week and occasional flashbacks. He had been living with his girlfriend for 40 years and he indicated that they got along "okay". He denied feeling helpless or hopeless but he complained of an inability to tolerate crowds. On mental status examination, he was oriented, casually dressed, and had fair personal hygiene and grooming. Speech was coherent and clear, his mood was sad, and his affect was appropriate for his mood. Eye contact, impulse control, concentration, judgment, and insight were fair. He denied suicidal or homicidal ideation and hallucinations. There were no abnormal movements. His memory for past and recent events and immediate recall were good. He had no problems focusing and psychosis was not found. A GAF score of 55 was assigned. An August 2012 VA psychiatric treatment note located in the Veteran's Virtual file shows he reported that his medication helped calm him and improved his sleep and mood. He was not feeling helplessness or hopelessness and although he had a good relationship with his girlfriend, his socialization was poor and he could no longer engage in leisure activities due to health problems. Since discontinuing one of his medications he had an increase in PTSD symptoms, which included being hypervigilant, restless, on edge, easily fatigued, having decreased concentration, and increased irritability. He had weekly flashbacks and nightmares, and occasional outbursts. He was anxious and in a better mood except for the escalation in PTSD symptoms. He was concerned about his GAF score and indicated that he could not get an increase in his disability without a score in the 50s. On mental status examination, he was oriented, casually dressed, and demonstrated fair personal hygiene and grooming. His speech was clear, coherent, and relevant. His mood was sad with an appropriate affect to his mood. Eye contact was good and he denied suicidal or homicidal ideation and hallucinations. There was no abnormal motor activity and he was goal-oriented with no problem focusing. His memory for past events was fair and for recent events was good. His GAF score was 50 to 52. An August 2012 depression screening located in his Virtual file indicates there was no evidence of depression. Based on a thorough review of the record, the Veteran's PTSD is shown to more closely approximate the criteria for a higher rating of 70 percent throughout the appeal. The Veteran's impairment in social function is found to be significant . Throughout the appeal his impairment in his social functioning was manifested by a fear and dislike of going into crowded places, social withdrawal, and poor socialization. See VA treatment records in August 2008, September 2009, July 2012, and August 2012, and VA examination reports in February 2009 and April 2012. Another area of impairment is the Veteran's mood. Throughout the appeal his mood is shown to be affected my multiple symptoms that include irritability, anger, depression, decreased or lack of motivation, sadness, and anxiousness. See July 2008, August 2008, August 2009, October 2011, April 2012 , and July 2012 VA treatment records and the April 2012 VA examination report. In addition, his judgment has been described only as fair, and his thinking was impaired (i.e., poor concentration and decreased memory). Of significance, there are medical opinions of record indicating that PTSD prevent him from effectively maintaining employment. In view of the foregoing, the Board finds that the Veteran's PTSD produces occupational and social impairment, with deficiencies in most areas, such that a 70 percent rating is warranted. However, the preponderance of the evidence is against entitlement to a 100 percent schedular rating for PTSD. The Veteran reported visiting with friends, his brother, and his girlfriend's family and friends. See VA examination reports in February 2009 and April 2012. He also reported going to a July 4th event and occasionally going to the store with his girlfriend, out to dinner, and to meetings. See the August 2010 VA treatment record and the April 2012 VA examination. Additionally, the Veteran reported keeping in contact with his other siblings. See the April 2012 VA examination report. The Veteran has maintained a stable relationship with his girlfriend for more than 40 years and he maintains contact with all of his siblings. In short, even though the Veteran's PTSD prevents him from effectively maintaining employment, the evidence does not support a finding of total social impairment. Therefore, a 100 percent schedular rating is not warranted. Accordingly, considering all of the evidence of record, the Board finds that the Veteran's total disability picture most closely approximates the criteria for a 70 percent disability rating; however, because he does not demonstrate total occupational and social impairment, a 100 percent rating is not warranted. Therefore, an increased rating of 70 percent, and not higher, for PTSD is granted. Extraschedular Consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b) (2012). The Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or 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 inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 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 C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's PTSD are not shown to cause any impairment that is not already contemplated by the rating criteria. As noted in Mauerhan, the rating criteria do not contain an exhaustive list of symptoms associated with mental health disorder. Therefore, while the Veteran may exhibit some of the listed symptoms but the fact that other symptoms may not be listed does not render the symptoms unusual or exceptional. What must be considered more closely in terms of the criteria is how the symptoms impact the Veteran socially and occupationally. In this regard, the Board finds that the various symptoms endorsed by the Veteran, which has been discussed at length above, produce a level of impairment found within the rating criteria. There is nothing in his reported symptomatology or in how it affects him that is considered unusual or exceptional. For these reasons, referral for consideration of an extraschedular rating is not warranted in this case. Legal Criteria and Analysis for Entitlement to a TDIU The Veteran contends that he is entitled to a TDIU and that because of his service-connected disability he is unable to retain or obtain employment. 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). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. §§ 3.321(b) , 4.16(b). Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In this regard, the Board highlights that the ability to work only a few hours a day or only sporadically is not the ability to engage in substantially gainful employment. Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Rather, the Court has held that "substantially gainful employment" suggests a "living wage." Ferraro v. Derwinski, 1 Vet. App. 326, 331 (1991). In determining whether a Veteran is entitled to TDIU, 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). In making this determination, 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 is in effect for ischemic heart disease (30 percent), PTSD (now 70 percent), diabetes mellitus (20 percent), a left ankle disorder (10 percent (10 percent), tinnitus (10 percent), diabetic neuropathy of the left lower extremity (10 percent), diabetic neuropathy of the right lower extremity (10 percent), bilateral hearing loss (0 percent), and erectile dysfunction (0 percent). The combined rating meets the percentage requirements of 38 C.F.R. § 4.16 (a). A July 2008 VA psychiatric record notes that the Veteran highest level of education is 12th grade. Although he reported that he first became disabled since 1995 due to a work related injury and that he received benefits from the Social Security Administration as a result of this injury, the record also shows that independent of this nonservice-connected disability the Veteran's service-connected PTSD is so severe that he is unable to follow a substantially gainful occupation. The Veteran's last employment was at a car dealer working 30 hours a week. He performed this job from 1982 to 1994. See TDIU claim received in March 2010. On February 2009 VA PTSD examination, the Veteran reported having a high school education and denied any additional formal education or training. His prior employment consisted of working as a maintenance man at a lead mine for 15 years. He was also self-employed for approximately 13 years as a car salesman, but stopped this type of work due to back problems. August and September 2009 statements from the Veteran's VA psychiatrist notes various symptoms of the Veteran's PTSD and stated that these symptoms prevented him from effectively maintaining any type of employable position. A September 2009 statement from the Veteran's long-term girlfriend notes the Veteran's service-connected disabilities and indicates that his symptoms prevent him from being employed. The Veteran underwent VA examinations in April and May 2012 to obtain opinions regarding his employability. The psychologist who examined him in April 2012 noted the Veteran's symptoms and their impact on his functioning. Moreover, he opined that based on the current evaluation and the information available that the Veteran did not appear to meet the criteria for unemployability based solely on his service-connected PTSD. The May 2012 VA general medical examination evaluated several disabilities and addressed their impact on the Veteran's ability to function. Opinions were also offered regarding their effect on his ability to obtain and maintain employment. Regarding the service-connected heart disability, the examiner indicated that it did impact the Veteran's ability to work in that he would have difficulty with any job involving labor. He added that the Veteran only had a high school education without any other skills. He opined that the Veteran was more likely "IU" secondary to ischemic heart disease. The examiner also referred to the March 2011 VA examination, which commented on the impact of the heart disorder on the Veteran's usual occupation and daily activities. The March 2011 opinion was that the heart disorder caused great difficulty completing everyday tasks. On the May 2012 VA examination, erectile dysfunction, diabetes mellitus, and peripheral neuropathy were found to not have any impact on his ability to work. Although not service-connected, an opinion was provided regarding the Veteran's low back disorder, which did impact the Veteran's ability to do labor-type work. An October 2012 letter from V. G, a private physician, states that she evaluated the Veteran to assess his ability to maintain gainful employment. She noted that the Veteran suffered with heart disease, diabetes with peripheral neuropathy in both legs, hearing loss with tinnitus, a left ankle injury, and PTSD. Some records from the Veteran's psychiatrist were reviewed and she noted that it was determined he would have difficulty with most types of employment. She opined that, "with his history and continuing issues with mood and concentration, that he would have difficulty with any type of employment. He lacks the ability to concentrate on tasks and would have difficulty with interacting with persons in the course of a job. His other health issues would affect his ability to have the stamina needed for a position, several of his medications cause sedation that would preclude employment, and his mood disorder is too severe to permit employment - he is not acceptable for active or sedentary employment per his history." An October 2012 letter from R. P., an employer with Reynolds County, states that the Veteran came to him in search of sedentary employment. After the interview, he was deemed not capable of performing the job. R. P. stated that the Veteran could not stay focused during the interview and he was unable to keep up with answering questions. The Veteran was found to be on several medications, some of which caused drowsiness. There was concern that he would not be able to deal with the public since many members of the public came in angry over tax bills. He added that the Veteran has always done manual labor and that it was late to retrain him to do office work. He opined that the Veteran was not capable of holding a job, sedentary or otherwise. A November 2012 letter from M. S., a private physician who intermittently treated the Veteran since July 2008, states that he evaluated the Veteran for the purpose of assessing his ability to maintain meaningful and gainful employment. He specifically noted the Veteran's PTSD, ischemic heart disease, diabetes, and peripheral neuropathy in the lower extremities. Records the physician reviewed included a letter from potential employer who was unable to hire the Veteran for a sedentary position due to his inability to relate to the public and concerns over his ability to control his anger due to PTSD. The physician opined that the Veteran's issues with mood, concentration, and difficulty with memory precluded any meaningful employment. He added that other issues, including peripheral neuropathy made it extremely difficult for the Veteran to ambulate, and to rise and sit in a chair. His multiple health issues also directly impacted his stamina and ability to work 6 to 8 hours. Here, the Board is faced with conflicting opinions as to the impact the service-connected disability has on the Veteran's employability. It is the Board's principal responsibility to assess the credibility and weight of all the 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 claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support [the] opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999); see also Black v. Brown, 5 Vet. App. 177, 180 (1993). The opinion offered by April 2012 VA examiner only considered the Veteran's PTSD and is against the claim. However, no rationale was provided, which frustrates the Board's ability to weigh it against other evidence of record. The opinion, therefore, cannot be afforded any probative value. A November 2012 letter from M. S., a private physician who intermittently treated the Veteran since July 2008, states that he evaluated the Veteran for the purpose of assessing his ability to maintain meaningful and gainful employment. He reviewed included a letter from potential employer who was unable to hire the Veteran for a sedentary position due to his inability to relate to the public and concerns over his ability to control his anger due to PTSD. The physician opined that the Veteran's issues with mood, concentration, and difficulty with memory precluded any meaningful employment. Having weighed evidence of record, the Board finds that a preponderance of the evidence supports a finding that the Veteran is incapable of securing and following substantially gainful employment as a result of his service-connected PTSD. Accordingly, a TDIU is warranted. ORDER An initial 70 percent rating for PTSD is granted, subject to the law and regulations governing payment of monetary benefits. A TDIU is granted. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs