Citation Nr: 1311222 Decision Date: 04/04/13 Archive Date: 04/19/13 DOCKET NO. 08-21 725 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to a disability evaluation in excess of 50 percent prior to September 13, 2010, and in excess of 70 percent from September 13, 2010 forward for service-connected depressive disorder, not otherwise specified ("NOS"), and panic disorder with agoraphobia. 2. Entitlement to a disability evaluation in excess of 30 percent prior to December 13, 2011, and in excess of 60 percent from December 13, 2011 forward for obstructive lung disease with mild centrilobular emphysema (formerly chronic interstitial lung disease associated with reactive airway disease or asthma). 3. Entitlement to service connection for prostate cancer, to include as a result of exposure to polyurethane paint in service. 4. Entitlement to a total rating based on individual unemployability due to service-connected disability ("TDIU"). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. Y. Hawkins, Counsel INTRODUCTION The Veteran served on active duty from April 1977 to June 1980. These matters come before the Board of Veterans' Appeals ("Board") on appeal from rating decisions issued by the Department of Veterans Affairs ("VA") Regional Office ("RO") in Denver, Colorado. In an August 2007 rating decision, the RO denied service connection for prostate cancer. In an October 2009 rating decision, the RO continued a 30 percent rating for the Veteran's current lung disability. In a December 2012 rating decision, the Appeals Management Center ("AMC") increased the disability rating to 60 percent, effective December 13, 2011. In a February 2010 rating decision, the RO continued a 50 percent rating for depressive disorder, NOS, and panic disorder with agoraphobia. In the December 2012 rating decision, the AMC increased the disability rating to 70 percent, effective September 13, 2010. Despite the assignment of increased disability evaluations for these disorders, the issues remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (a rating decision issued after a notice of disagreement which grants less than the maximum rating available does not "abrogate the pending appeal"). In June 2011, the Veteran presented testimony during a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's claims folder. The Board has previously considered these claims. In October 2010, the Board remanded the claims for additional evidentiary development, specifically, to obtain additional treatment records and afford the Veteran new VA examinations. Thereafter, in a December 2012 Supplemental Statement of the Case ("SSOC"), the issues on appeal were readjudicated. There has been substantial compliance with the October 2010 remand, as the Veteran has been provided the requisite examinations and relevant records have been obtained and associated with the record. The claims have been returned to the Board for further appellate proceedings. The record reflects that the appellant has submitted additional evidence to the Board in conjunction with this case, accompanied by a waiver of initial review of the evidence by the agency of original jurisdiction in accord with 38 C.F.R. § 20.1304 (2012). The Board accepts this evidence for inclusion in the record. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC in Washington, DC. The Veteran will be notified if additional action is required on his part. FINDINGS OF FACT 1. Prior to September 13, 2010, the Veteran's depressive disorder, NOS, and panic disorder with agoraphobia was manifested by anger and irritability; flattened affect; panic attacks more than once a week; impairment of short and long-term memory; impaired judgment; disturbances of motivation and mood; suicidal ideation; and difficulty in establishing and maintaining effective work and social relationships. 2. As of September 13, 2010, the Veteran's depressive disorder, NOS, and panic disorder with agoraphobia resulted in his unemployability. 3. Prior to December 13, 2011, the Veteran's service-connected lung disease was manifested by the use of daily inhalation bronchodilator therapy. 4. Since December 13, 2011, the Veteran's service-connected lung disease has been manifested by post-bronchodilator FEV-1 of 52 percent predicted. 5. The most probative evidence of record demonstrates that the Veteran's prostate cancer is not is not etiologically-related to any aspect of service, to include exposure to polyurethane paint. CONCLUSIONS OF LAW 1. For the period prior to September 13, 2010, the criteria for a disability evaluation in excess of 50 percent for depressive disorder, NOS, and panic disorder with agoraphobia were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.27, 4.126, 4.130, Diagnostic Code 9434 (2012). 2. For the period September 13, 2010 forward, the criteria for a disability evaluation of 100 percent for depressive disorder, NOS, and panic disorder with agoraphobia have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.27, 4.126, 4.130, Diagnostic Code 9434 (2012). 3. For the period prior to December 13, 2011, the criteria for a disability evaluation in excess of 30 percent for the service-connected lung disease were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.97, Diagnostic Code 6828-6602 (2012). 4. For the period December 13, 2011 forward, the criteria for a disability evaluation in excess of 60 percent for the service-connected respiratory disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.97, Diagnostic Code 6604 (2012). 5. The Veteran's prostate cancer was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). A.) Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 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). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) ("Pelegrini II"), the United States Court of Appeals for Veterans Claims ("Court") held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his or her possession that pertains to the claim. Element (4), the requirement of requesting that the claimant provide any evidence in his or her possession that pertains to the claim, was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection is awarded. With regard to the Veteran's claims of entitlement to increased ratings for a depressive disorder and a lung disease, the Board notes that service connection had already been established and the current appeal arose from a claim for an increased disability rating. By means of a letter dated December 2009, the Veteran was informed that he should provide evidence showing that the symptoms of his service-connected depressive disorder had increased in severity. Similarly, by means of a letter dated May 2009, the Veteran was informed that he should provide evidence showing that the symptoms of his service-connected lung disease had increased in severity. These letters provided notice of the types of evidence, both lay and medical, that could be submitted in support of a claim for an increased rating, and advised the Veteran of what VA would do to assist him in obtaining such evidence. In a February 2007 letter, the Veteran was also informed of the types of evidence needed in order to substantiate his claim of entitlement to service connection for prostate cancer, the division of responsibility between himself and VA for obtaining the required evidence, and was asked to provide any information or evidence in his possession that pertained to such claim. 38 U.S.C.A. §5103(a); 38 C.F.R. § 3.159(b). The letters also satisfied the requirements of Dingess/Hartman and informed the Veteran of how VA determines the disability rating and effective date elements of a claim. B.) Duty to Assist The Board concludes that VA's duty to assist has been satisfied. The claims file contains the Veteran's service and post-service treatment records and multiple VA examination reports. Additionally, the claims file contains the Veteran's statements in support of his claims. The Veteran has not referenced any outstanding, available records that he wanted VA to obtain or that he felt were relevant to the claims that have not already been obtained and associated with the record. Review of the examination reports reveals that the examiners reviewed the Veteran's pertinent service and post-service treatment records, performed the necessary examinations, including a review of diagnostic test results, elicited from the Veteran his history of symptomatology associated with the disorders, and provided clinical findings detailing the results of the examinations. For these reasons, the Board concludes that the examination reports are adequate upon which to make decisions on these claims. Accordingly, the Board finds that VA has fully complied with the notice and assistance requirements of the VCAA and its regulations. The appellant has been provided with every opportunity to submit evidence and argument in support of his claims, and to respond to the VCAA notice. The purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his appealed claims. Accordingly, the Board will proceed to a decision on the merits. II. Analysis 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 claimant. 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, VA 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 the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting its 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 claims. 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). Under 38 U.S.C.A. § 1154(a), VA is also required to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. In Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit ("Federal Circuit") held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3), lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." (footnote omitted). However, the Court has held that "[t]he type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed." Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, and by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries, and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate Diagnostic Codes ("DCs") identify the various disabilities and the criteria for specific ratings. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2009). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen. Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely-related disease or injury, in which both the functions affected and the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. A. Entitlement to a disability evaluation in excess of 50 percent prior to September 13, 2010, and in excess of 70 percent from September 13, 2010 forward for service-connected depressive disorder, NOS, and panic disorder with agoraphobia. When evaluating a mental disorder, the rating agency shall 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 shall 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 will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). The Veteran's service-connected major depressive disorder has been evaluated under DC 9434 (2012). The regulations establish a general rating formula for mental disabilities. See 38 C.F.R. § 4.130 (2012). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase 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. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) ("DSM-IV"). The criteria for a 50 percent rating are: 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; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: 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 worklike setting); inability to establish and maintain effective relationships. And, the criteria for a 100 percent rating are: 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. See 38 C.F.R. § 4.130, Diagnostic Code 9434 (2012). The Board must also consider the Global Assessment of Functioning ("GAF") scores that have been reported. GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the DSM-IV, p.32). GAF scores from 61 to 70 represent some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful personal relationships. GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school function (such as few friends, conflicts with peers or co-workers). GAF scores ranging from 41 to 50 reflect 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). Additionally, scores ranging from 31 to 40 reflect 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 other children, is defiant at home, and is failing at school). Lower scores assess increased impairment. Review of the claims folder shows that the Veteran was afforded a VA mental health compensation and pension examination in August 2008. During the evaluation, the Veteran reported experiencing symptoms of depression and anxiety. He also reported trouble sleeping, bad dreams, suicidal ideations and panic attacks one to two times per week. During the mental status evaluation, he was neatly-dressed, his mood was depressed, his affect was extremely restricted, and his memory and concentration levels were impaired. The examiner noted that there has been a progressive worsening of his condition over the years without remission. While he noted that the Veteran's social functioning was impaired by his psychiatric disorder, he found no limitation to his ability to work. The diagnoses were depressive disorder, NOS, and panic disorder. The assigned GAF score was 55, representative of moderate symptoms. In January 2010, the Veteran was afforded another VA psychiatric evaluation. At that time, it was noted that he had recently been seen at the local VA Medical Center ("VAMC"), where he reported an increase in his dreams of dying and enraged outbursts at others, and noted that his panic attacks were still occurring about twice per week. During the examination, he reported great difficulty leaving his home, which caused increased anxiety. He noted that he was missing substantial time from work. He also described sleep difficulties and problems with his memory. He added that he was chronically discouraged. During the mental status evaluation, the examiner administered a test, in which he concluded that the Veteran had difficulty maintaining attention to the degree that it suggested a cognitive disorder. It was further observed that the Veteran was quite irritable and querulous. He expressed feelings of anger at persons who can enjoy things in their lives and said he sometimes felt life was not worth living. Despite these suicidal ideations, he expressed no specific suicidal plans. The examiner assigned a GAF score of 52 based on panic disorder, 58 based on depressive disorder, and 52 based on cognitive disorder. He added that the Veteran was able to maintain his activities of daily living, including personal hygiene, and added that not only was his social functioning impaired, but his employment was also impaired, as he was continuing to miss significant amounts of time from work, sometimes as much as 50 percent. On September 13, 2010, the Veteran attended an outpatient psychiatric session for medication management. While he reported no change in his anxiety, he said he was more depressed and discouraged than ever, mainly due to lack of progress with his lung disease symptoms. He said he "might just as well be dead." During the mental status evaluation, he was cooperative with normal speech and good grooming and hygiene. His mood was moderately dysphoric and his affect was non-labile, congruent, somewhat subdued and distant. Thought process was logical and thought content contained some passive suicidal ideations without plan. Cognitive ability and insight/judgment were grossly intact. The clinician assigned a GAF score of 40. During an April 2011 VAMC outpatient psychiatric evaluation, the clinician noted that the Veteran's mood and anxiety appeared to be worse. The Veteran reported continuing sleep difficulties and added that he felt his prescribed medication was not working very well. During the mental status evaluation, he displayed good grooming and hygiene, normal speech and moderately dysphoric mood. The assigned GAF score was 46, reflective of serious symptoms. In August 2011, it was noted that the Veteran was attempting work as a part-time car salesman but was struggling. During a December 2011 VA psychiatric examination, the Veteran reported experiencing sleep problems, chronic anxiety and depression. He expressed pervasive worry and negativity about the way he perceived being treated in obtaining his medical care. He said he now experienced daily panic attacks, resulting in his often leaving work early. He also reported an increase in depression, especially following the recent death of his mother in April 2011, as well as two friends who both died of cancer. He denied auditory or visual hallucinations, as well as any problems maintaining personal hygiene (adding that he showered every workday). He expressed a reluctance to go into open spaces for fear of getting a panic attack. He denied any history of suicide attempts, but admitted to occasional suicidal thoughts without any current intent or plan. He also complained of chronic problems with short-term memory and concentration and displayed some mild memory loss. During the mental status evaluation, he was polite, cooperative and soft-spoken. He denied persistent auditory or visual hallucinations. It was noted that he had good attention throughout the entire interview, without evidence of pervasive difficulty with concentration. The examiner assigned a GAF score of 52 for panic disorder with depression. During a December 2011 VA psychotherapy session, the clinician noted that the Veteran still suffered from longstanding depression and anxiety, stating that he had seen little progress since working with him. He noted that the Veteran was frequently too anxious or depressed to leave the house, and concluded that he was unemployable. In February 2012, it was noted that he was not getting to his job at the car dealership very often. In May 2012, the Veteran said that he was experiencing an increased in anxiety and dysphoria. He added that he had barely been working and would have been fired had his employer not been a friend of his. The clinician noted that he had good grooming and hygiene, and was cooperative with normal speech, a logical thought process, and some passive suicidal thoughts without plan (although, Veteran said he was thinking about "joining his [dead] mother"). There was no evidence of homicidal ideation or intent. His cognitive ability was grossly intact without psychotic symptoms, as was his insight and judgment. The assigned GAF score was 45. In July 2012, during a VA outpatient psychotherapy session, the Veteran reported that he had been having more frequent panic attacks, and the previous week, had been fired from his job as a car salesman. The clinician wrote that it was unlikely that he would be able to maintain any employment, however, due to his chronic depression and panic attacks. A July 2012 medication management note indicates that the Veteran reported that he was missing too much work so he was fired from his sales job. He related that he had taken a financial hit but was not making much money anyway. An October 2012 VA mental health note reflects that the Veteran had gotten a new part time job selling cars but was not sure how long it would last given that he was missing work and leaving early due to depression and anxiety. An October 2012 medication management note reflects that the Veteran's level of functioning on the job appeared to be quite poor. In a January 2013 statement, the Veteran's VA psychiatrist indicated that the Veteran had been receiving outpatient treatment for depression and panic disorder. It was noted that despite the use of multiple medication trials, as well as psychotherapy, he continued to have very frequent anxiety attacks, a depressed mood, decreased energy and motivation, isolativeness, and an inability to deal with people on any kind of consistent basis. It was noted that both disorders contribute to serious debilitation and inability to function in a competitive work environment. It was noted he had tried several times in recent years to work even part time as a car salesman, but he frequently could not even leave the house to go to work and when he did get to work he often had to leave and return home because of anxiety attacks or trouble breathing. It was opined that the Veteran was clinically unemployable. After a careful review of the complete claims folder, the Board concludes that, for the period prior to September 13, 2010, the Veteran's depressive disorder, NOS, and panic disorder with agoraphobia more closely approximated the criteria for a 50 percent disability evaluation under DC 9434. Although the symptoms of his disorder at that time were persistent, resulting in social and occupational difficulties, there was no evidence of symptoms that more closely approximate the criteria for a 70 percent disability rating, including 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; spatial disorientation; neglect of personal appearance and hygiene; and an inability to establish and maintain effective relationships. In reaching this conclusion, as noted above, the Board observes that, during this period, the symptoms from the Veteran's psychiatric disorder were generally moderate in nature, and were manifested by panic attacks more than once a week; disturbances of motivation and mood; suicidal ideation; and difficulty in establishing and maintaining effective work and social relationships. In addition, his GAF scores for the period prior to September 13, 2010 ranged between 51 and 58, which represent moderate symptoms. Moreover, while the Veteran reported experiencing suicidal ideations without plan or intent, the Court has held that the symptoms listed in the rating criteria are not intended to constitute an exhaustive list, and that VA must instead consider all symptoms of a claimant's disability that affect the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436. As such, the Board finds that, for this portion of the appeals period, a higher 70 percent disability rating is not warranted. In addition to the VA examinations and outpatient treatment reports, the Board has also considered the Veteran's personal statements (as well as those of his wife) regarding the severity of his disorder. In this regard, the Board is cognizant that the Court has repeatedly held that a veteran is competent to describe symptoms of which he or she has first-hand knowledge. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). However, the Court has also held that a lay person is not competent to offer an opinion on a matter clearly requiring medical expertise, such as evaluating the complex manifestations of a psychiatric disorder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As a result, his assertions do not constitute competent medical evidence. The Board has also considered the potential application of 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. 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 claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant'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 extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected psychiatric disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's condition with the established rating criteria shows that the rating criteria adequately describe the Veteran's symptomatology and disability level. Higher evaluations are provided for greater levels of severity of the disorder. There is no unusual clinical picture presented or any other factor which takes the disability outside the usual rating criteria. Thus, referral for an extraschedular rating is not warranted. For the period September 13, 2010 forward, the Board concludes that the Veteran's depressive disorder, NOS, and panic disorder with agoraphobia has more closely approximates the criteria for a 100 percent schedular rating under DC 9434. Notably, VA treatment records reflect there was a dramatic increase in symptomatology in late 2010. His assigned GAF scores fell to 40 which is indicative of major impairment in areas such as work and family relations. Months later, in April 2011, the Veteran continued to have serious problems, and was assessed as having a GAF score of 46. The examiner indicated that his anxiety and mood had worsened. On VA examination in December 2011, it was noted he had daily panic attacks. While the VA compensation and pension examiner essentially indicated that his psychiatric symptoms were moderate, another treating VA physician contemporaneously indicated that his psychiatric problems rendered him unemployable. Ongoing VA treatment records in 2012 support this finding of unemployability. Although he variously reported working as a part time car salesman, the work was described intermittent and arranged by a friend. More often than not, the Veteran indicated that he was unable to go to work. His part time job was clearly far from gainful employment. The Veteran's treating VA psychotherapist has repeatedly indicated his belief that the Veteran's anxiety and depression had increased so much that he believed him to no longer be employable. See generally January 2013 statement; 2011 VA treatment records. In sum, as of September 13, 2010 forward, the Board finds that the Veteran met the scheduler criteria for a 100 percent rating for depressive disorder, NOS and panic disorder with agoraphobia. B. Entitlement to a disability evaluation in excess of 30 percent prior to December 13, 2011 for service-connected lung disease, and a disability evaluation in excess of 60 percent from December 13, 2011 forward for service-connected lung disease During the portion of the appeal prior to December 13, 2011, the Veteran's condition, diagnosed as chronic interstitial lung disease associated with reactive airway disease or asthma, was rated by analogy to DC 6828-6602. Pursuant to DC 6828, eosinophilic granuloma of the lung is evaluated pursuant to the General Rating Formula for Interstitial Lung Disease. This formula provides for evaluations from 10 to 100 percent based on findings from a Pulmonary Function Test ("PFT"), in particular, Forced Vital Capacity ("FVC") and Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method ("DLCO (SB)"), as well as the maximum oxygen consumption in ml/kg/min. 38 C.F.R. § 4.97, DC 6828. Eosinophilic granuloma of the lung is rated pursuant to the following criteria: A 100 percent evaluation is assigned for FVC less than 50 percent of predicted value, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption with cardiorespiratory limitation, or; cor pulmonale (right heart failure) or pulmonary hypertension, or; requires outpatient oxygen therapy. A 60 percent evaluation is assigned for FVC of 50- to 64-percent predicted, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum exercise capacity of 15 to 20 ml/kg/min oxygen consumption with cardiorespiratory limitation. A 30 percent evaluation is assigned for FVC of 65- to 74-percent predicted, or; DLCO (SB) of 56- to 65- percent predicted. A 10 percent evaluation is assigned for FVC of 75- to 80-percent predicted value, or; DLCO (SB) of 66- to 80-percent predicted. 38 C.F.R. § 4.97, DC 6828. Pursuant to DC 6602, bronchial asthma is also evaluated on the basis of findings from a PFT, in particular, Forced Expiratory Volume in one second ("FEV-1") and Forced Expiratory Volume in one second/Forced Vital Capacity ("FEV-1/FVC"). Bronchial asthma is rated pursuant to the following criteria: A 100 percent disability rating is warranted for an FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. A 60 percent disability rating is warranted for an FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 30 percent rating is warranted for an FEV-1 of 56 to 70 percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication. A 10 percent rating is warranted for an FEV-1 of 71 to 80 percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy. Note: In the absence of clinical findings of asthma at the time of examination, a verified history of asthmatic attacks must be of record. 38 C.F.R. § 4.97, DC 6602. Pursuant to DC 6604, chronic obstructive pulmonary disease ("COPD") is rated pursuant to the following criteria: A 100 percent rating is assigned for an FEV-1 less than 40 percent of predicted value, or the ratio of FEV-1/FVC less than 40 percent, or DLCO (SB) less than 40 percent predicted, or maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or right ventricular hypertrophy, or pulmonary hypertension (shown by Echo or cardiac catheterization), or episode(s) of acute respiratory failure, or the requirement for outpatient oxygen therapy. A 60 percent evaluation is assigned for an FEV-1 of 40 to 55 percent predicted, or FEV-1/FVC of 40 to 55 percent, or DLCO (SB) of 40 to 55 percent predicted, or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 30 percent rating is assigned for an FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56 to 65 percent predicted. A 10 percent evaluation is assigned for an FEV-1 of 71 to 80 percent, or; FEV-1/FVC of 71 to 80 percent, or DLCO (SB) 66 to 80 percent predicted. 38 C.F.R. § 4.97, DC 6604. In evaluating certain respiratory disorders, including the one at issue, pulmonary function tests are required, except in the following circumstances: (i) when the results of a maximum exercise capacity test are of record and are 20 ml/kg/min or less; if a maximum exercise capacity test is not of record, evaluation is based on alternative criteria; (ii) when pulmonary hypertension (documented by an echocardiogram or cardiac catheterization), cor pulmonale, or right ventricular hypertrophy has been diagnosed; (iii) when there have been one or more episodes of acute respiratory failure; (iv) when outpatient oxygen therapy is required. 38 C.F.R. § 4.96(d)(1). For interstitial lung disease, the pulmonary function test findings used for rating purposes are FVC and DLCO. See 38 C.F.R. § 4.97 (DC's 6825-6833). Post-bronchodilator results are required when pulmonary function tests are done for disability evaluation purposes except when the results of pre-bronchodilator pulmonary function tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. See 38 C.F.R. § 4.96(d)(4) . In applying the rating criteria, post-bronchodilator results are to be used unless the post-bronchodilator results were poorer than the pre-bronchodilator results, in which case the pre-bronchodilator values should be used for rating purposes. 38 C.F.R. § 4.96(d)(5). Therefore, only the better of the two results will be discussed below. The Board now turns to a discussion of the relevant evidence of record. During an August 2008 VA compensation and pension examination, a pulmonary function test reflected pre-bronchodilator FEV-1 of 77 percent predicted and pre-bronchodilator FEV-1/FVC of 101 percent predicted. Post-bronchodilator values were not indicated, and DLCO was not done. The examiner indicated that the results were questionable and that interpretation was limited. In September 2009, during a VA compensation and pension examination, a PFT demonstrated post-bronchodilator FVC of 86 percent predicted, post-bronchodilator FEV-1 of 83 percent predicted, and post-bronchodilator FEV-1/FVC of 78 percent predicted. DLCO was 91 percent predicted. Significantly, it was noted that the Veteran used the inhaled bronchodilator, albuterol, 2 puffs, 4 to 5 times per day. VA treatment records also include a December 2009 PFT. At that time, post-bronchodilator FVC was 70 percent predicted, post-bronchodilator FEV-1 was 69 percent predicted, and post-bronchodilator FEV-1/FVC was 80 percent predicted. DLCO was 85 percent predicted. The physician noted that these were suboptimal test results and that the Veteran's decreased DLCO normalized with DLCO/VA, suggesting a loss of lung volume. During a July 2010 PFT, post-bronchodilator FVC was 70 percent predicted, post-bronchodilator FEV-1 was 23 percent predicted, and post-bronchodilator FEV-1/FVC was 26 percent predicted. The clinician noted, however, that these were questionable test results, which limited interpretation, and suggested that the test might need to be repeated. In December 2011, the Veteran was afforded another lung evaluation. At this time, however, the VA examiner diagnosed the Veteran with chronic obstructive lung disease with mild or partial reversibility by bronchodilators. Based on a lack of data such as lung biopsies and chest CT radiographs, there was no objective evidence to support the previous diagnosis of interstitial disease stable, eosinophilic granuloma. This finding was also based on the normal DLCO and PFTs showing obstructive lung disease. He noted that there had been no use of systemic steroids for immunosuppressants. He further observed that the Veteran's last chest CT in April 2010 revealed mild centrilobular emphysema. The examiner also explained why he was unable to do a full PFT, including diffusion capacity single breath and maximum oxygen consumption tests, noting that the maximum oxygen consumption test requires vigorous exercise, to include even in the less demanding modified Cooper protocol running 12 minutes, and entails some cardiac risks that require full monitoring and preparedness to initiate full ACLS intervention. He noted that the Veteran would not be able to run to this extent, partly because of his de-conditioning and partly because of his degenerative arthritis knee pain. During the examination, a PFT demonstrated pre-bronchodilator FVC of 70 predicted and post-bronchodilator FVC of 71 predicted; pre-bronchodilator FEV-1 of 46 percent predicted and post-bronchodilator FEV-1 of 52 percent predicted; and pre-bronchodilator FEV-1/FVC of 64 percent predicted and post-bronchodilator FEV-1/FVC of 72 percent predicted. DLCO was 101 percent predicted. With regard to the VA 2010 PFTs, the examiner noted that the most significant data demonstrating that the 2010 PFTs were "clearly the inconsistent and least valid set of data" was the evidence of obstructive pulmonary disease based on the FVC and only partial responsiveness to bronchodilator as best demonstrated by the +12 % increase in FEV1 before and after albuterol, but only to 1.75 L or 52% of FEV1 predicted after bronchodilation. He further noted that the FEV1 is also used as part of the Gold Criteria for staging the severity of chronic obstructive lung disease. He added that the normal DLCO argues against the presence of any interstitial lung disease. In a November 2012 VA compensation addendum it was noted that the Veteran's PFTSs in December 2011 represented a significant deterioration in his capacity to breathe as compared to his 2009 PFTs. It was noted that FEV1 was 46 percent and there was a 12 percent change with bronchodilation. It was noted that 46 percent defined his COPD. It was noted that FEV1/FVC was 64 percent, and there was a 11 percent change with bronchodilation. (The aforementioned findings are pre-bronchodilator.) It was concluded that the Veteran had progressive COPD with mild centrilobular emphysema. After carefully reviewing the evidence of record, the Board finds that, for the period prior to December 13, 2011, the Veteran's PFT results do not support a rating in excess of 30 percent. Preliminarily, as discussed above, the Board must discount the probative value of the August 2008 PFTs because these records are described as questionable and do not indicate that a post-bronchodilator test was performed. See 38 C.F.R. § 4.96(d)(4). Thus, the Board gives more weight to the VA PFTs which are based on both pre- and post-bronchodilator tests. See Id. In addition, the Board accords less probative weight to the results of the December 2009 PFT, at which time, the physician noted that these were suboptimal test results and that the Veteran's decreased DLCO normalized with DLCO/VA, suggesting a loss of lung volume. Rather, for the period prior to December 13, 2011, the Board places the greatest probative weight on the September 2009 VA examination, at which time, it was noted that the Veteran was using daily inhalation bronchodilator therapy. Accordingly, under DC 6602, no more than the current disability evaluation of 30 percent is warranted. A higher, 60 percent evaluation is not warranted during the portion of the appeals period, as there is no evidence that the Veteran required at least monthly visits to a physician for required care of exacerbations, or intermittent courses of systemic corticosteroids. Moreover, as noted above, there is no indication that he had FEV-1 of 40- to 55 percent predicted, or FEV-1/FVC less than 40 percent. Moreover, even considering the possibility of a diagnosis of obstructive lung disease with mild centrilobular emphysema as early as April 2010, because the July 2010 VA examiner found that the results of the tests were questionable and limited interpretation, as did the December 2011 examiner, who found them to be inconsistent, as discussed above, the Board accords that these PFTs are of less probative weight. Moreover, even if the Board were to assume these results were correct, the subsequent December 2011 examination would mean there was a substantial improvement in the Veteran's lung disorder, with an FEV-1 of 23 percent of predicted value, to an FEV-1 of 52 percent of predicted value. As there is no probative evidence to show such a dramatic improvement in the Veteran's condition, the Board accords greater weight to the December 2011 examination results, during which the examiner provided a well-rationed explanation for the updated diagnosis of COPD. For the period December 13, 2011 forward, the Board concludes that the Veteran's FVC results do not support a rating in excess of the currently-assigned 60 percent. As noted above, during the December 2011 PFT, the results showed post-bronchodilator FEV-1/FVC of 72 percent predicted, which warrants a 60 percent disability evaluation under DC 6604 for COPD. As discussed above, at this time, the VA examiner determined, based on a chest CT, that the Veteran's lung condition was more consistent with a diagnosis of obstructive lung disease with mild centrilobular emphysema, and based on this the RO appropriately recharacterized the Veteran's service-connected disability. He specifically found that there was no objective evidence to support the previous diagnosis of interstitial disease stable, eosinophilic granuloma, and the condition was less fitting to the diagnosis of pure asthma. As such, the new diagnostic code has been applied. In addition to the VA examinations and outpatient treatment reports, the Board has again considered the Veteran's personal statements (as well as those of his wife) regarding the severity of his lung disorder. In this regard, the Board is cognizant that the Court has repeatedly held that a veteran is competent to describe symptoms of which he or she has first-hand knowledge. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). However, the Court has also held that a lay person is not competent to offer an opinion on a matter clearly requiring medical expertise, such as evaluating the complex manifestations of a respiratory disorder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As a result, his assertions do not constitute competent medical evidence. The Board has also considered whether an increased evaluation under other potentially applicable diagnostic codes is warranted. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc) (the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case."). However, because there is no medical evidence to show that he has been diagnosed with any other diseases of the trachea or bronchi, a higher disability rating under another diagnostic code is not warranted. The Board has also considered the potential application of 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the threshold determination is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Shinseki, supra. In this case, the Board concludes that the Veteran's service-connected lung disorder is not so unusual or exceptional in nature as to render the assigned schedular rating inadequate. The Veteran's disability has been evaluated under the applicable diagnostic codes that have specifically contemplated the level of occupational impairment caused by his disability. Higher ratings are available for greater levels of disability and increased symptoms. Therefore, referral for assignment of an extra-schedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). C. Entitlement to service connection for prostate cancer. The Veteran avers that he has prostate cancer related to his exposure to polyurethane paint during service. In order to establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) the in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, under 38 C.F.R. § 3.303(b), service connection may be awarded for a "chronic" condition when (1) a chronic disease manifests itself and is identified as such in service, or within the presumptive period under 38 C.F.R. § 3.307, and the veteran presently has the same condition; or (2) a chronic disease as listed in 38 C.F.R. § 3.309(a) manifests itself during service, or during the presumptive period, but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the Veteran's present condition. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity in diseases listed in 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b) (2012); Id. For certain chronic diseases (including malignant tumors) service connection may be established on a presumptive basis if they are manifested to a compensable degree within one year of service separation. 38 U.S.C.A. §§ 1112 , 1113, 1137; 38 C.F.R. §§ 3.307, 3.309 As an initial matter, review of the service treatment records shows no evidence that the Veteran complained of symptoms suggestive of, received treatment for, or was diagnosed with prostate cancer. His November 1976 enlistment examination revealed normal findings in all systems, as did his September 1979 physical. The Board notes, however, that a March 1980 Medical Board Report reflects that the Veteran had worked as an aircraft painter at the Naval Air Station and was exposed to polyurethane paints on multiple occasions. As such, exposure to polyurethane paints is conceded. There is no evidence that a malignant tumor of the prostate was diagnosed within one year of service separation. The Veteran was not diagnosed with prostate cancer until May 2006, while receiving treatment at his local VAMC. There is no evidence, however, that his physicians ever associated the disease with any aspect of service. An August 2006 record of VA treatment reflects that the Veteran asked a urology resident whether exposure to polyurethane paints during service could be responsible for his prostate cancer and presented articles he had obtained from the internet regarding such a relationship. The resident stated that he was not familiar with the environmental exposure of polyurethane paint, but that it was a possibility based on what was known about Agent Orange exposure. The resident added that, because prostate cancer has a very high prevalence in the United States, it would be difficult to single out solitary environmental exposures. During an October 2006 VA examination to evaluate his service-connected respiratory disability, the Veteran reported that he had been exposed to polyurethane paint while painting aircraft during service and stated his belief that the paint fumes had been an etiological factor affecting his lungs and prostate gland. The examiner commented that this would be discussed later, although he informed the Veteran that he did not have any information about polyurethane paint fumes. The examiner did opine, however, that there did not appear to be any connection between the Veteran's service-connected orchiectomy and his prostate cancer. The assessment following the examination included adenocarcinoma of the prostate, which did not bear any relation to the service-connected orchiectomy. During VA treatment in August 2007, the Veteran and another urology resident discussed the lack of class A scientific data supporting the causal relationship between environmental exposures and prostate cancer. The resident stated that it was possible that exposure to paint may cause prostate cancer, but she could not write a letter stating that there is a definite relationship. The following month, the chief of the urology section indicated that he had contacted medical oncology at the Denver VAMC and a medical oncologist at a university, who indicated that they could not write a letter supporting the Veteran's claim for service connection for prostate cancer. The physician noted that the evidence was just not available; however, he had been advised to contact a toxicologist or environmental epidemiologist. During treatment in November 2007, the chief of urology informed the Veteran that he had spoken with two toxicologists, who each indicated that they needed additional information. The Veteran was provided with the contact information for each toxicologist. An April 2008 VA record reflects that the Veteran's request for VA to pay for consultation with a toxicologist had been denied. The fee basis clerk indicated that there was no credible data that painting airplanes results in prostate cancer, nor was there any way that a toxicologist could prove this one way or another. The Veteran was advised that, if he wished to pursue this line of inquiry, he would need to do so at his own expense. In an April 2008 letter, Dr. M.J.K., a private toxicologist, indicated that he had been contacted by the Veteran, who requested a toxicology consultation regarding the role that his occupational exposure from painting aircraft in the Navy may have had on his development of prostate cancer. Dr. M.J.K. indicated that he had not evaluated the Veteran, but that aircraft painting is a common source of elevated exposure to cadmium, a metal which has been implicated as a cause of prostate cancer. The physician included some excerpts from medical literature regarding this relationship. He added that, without an evaluation, he could not comment on the specific etiology of the Veteran's prostate cancer; although based on his preliminary review, he believed that the matter was worthy of further consideration. In December 2011, the Veteran was afforded a VA examination to obtain a medical opinion as to the etiology of the Veteran's prostate cancer. The examiner noted that the Veteran served on active duty in the Navy with an MOS of a special mechanic which primarily involved painting planes. However, after performing a complete physical evaluation, including a review of diagnostic test results and a review of the complete claims folder, the VA examiner opined that the Veteran's prostate cancer was less likely than not incurred in, or caused by an injury, event or illness in service. In this regard, he noted that the study, "Cancer Investigation" 2005, 23(3), 256-263, notes no conclusive evidence of an association between cadmium and prostate cancer. He further noted that there is a MEDLINE database search of all studies involving this association and prostate cancer subjects between 1966-2002, including highly exposed cohorts who worked in nickel-cadmium battery plants. Of 11 cohort studies, there was only 3/11 or 27 percent that found an association. In another 4 cohort studies involving only highly exposed individuals to cadmium, such as the nickel-cadmium battery workers, there was a "weak[] but not significant positive association" with a 95 percent confidence interval. He also noted that, in a September 2011 report by A. Oliver Sarta, MD, et.al., of all known associations with prostate cancer, there was no inclusion of polyurethane paint or cadmium, dimethylformamide, or acrylonitrile. The examiner concluded that, given the weakness of any association, let alone evidence of causation, between these chemicals and prostate cancer, he maintained that it was less likely than not that the Veteran's prostate cancer was the direct result of his exposure to polyurethane paint or other environmental exposures while on active duty service. Moreover, he added that he had identified no other risk factors for prostate cancer resulting from to the Veteran's active duty service. Based on a review of the complete claims folder, the Board concludes that the probative evidence of record does not support the Veteran's contention that his prostate cancer is the result of any aspect of military service, to include as a result of polyurethane paint exposure. As noted above, although his service records demonstrate that he worked as an aircraft painter at the Naval Air Station and was exposed to polyurethane paints on multiple occasions, the VA examiner took a multitude of factors into consideration in arriving at his opinion that the condition was not related to service. The Board finds the opinion of the VA examiner, supported with reasons and bases, to be the most persuasive evidence of record as to the relationship between the Veteran's cancer and active duty service. In addition to the medical and military evidence of record, the Board has also considered the Veteran's personal contention that his cancer stems from exposure to polyurethane paint in service. In this regard, the Board notes that the Court has repeatedly held that individual claimants are considered competent to testify to matters that "lend[] [themselves] to observation by a lay witness." See Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). However, in this instance, the Veteran has not been shown to have the appropriate medical knowledge or training to render him competent to provide an opinion on such a complex issue, such as associating exposure to paint fumes several decades earlier with current prostate cancer. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Therefore, his assertions do not constitute competent medical evidence that the claimed disorder was caused by, or is otherwise related to his military service. Finally, the Board has also reviewed and considered the medical treatise evidence submitted by the Veteran in support of his claim. In this regard, the Board notes that treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). In addition, the Court has held that a medical article or treatise can provide support for a claim, but that it must be combined with an opinion of a medical professional and be reflective of the specific facts of a case as opposed to a discussion of generic relationships. Sacks v. West, 11 Vet. App. 314, 316-17 (1998); see Wallin v. West, 11 Vet. App. 509, 514 (1998) (medical treatise evidence discussed generic relationships with a degree of certainty to establish a plausible causality of nexus); see also Mattern v. West, 12 Vet. App. 222, 228 (1999). However, medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Here, although the Veteran has submitted articles discussing potential health consequences for individual exposed to metals and chemicals, including cadmium, dimethylformamide, and acrylonitrile, these articles fail to support his contention that his prostate cancer, diagnosed more than 25 years after service, was caused by polyurethane paint exposure. As such, the Board finds the documentation insufficient to show that the Veteran's disease is related to service. (Notably, the December 2011 VA opinion contains an exhaustive discussion of the medical literature addressing chemical exposure and prostate cancer; following, which it was concluded that the Veteran's prostate cancer was not attributable to polyurethane pain or other environmental exposures in service.) Accordingly, the Board concludes that the most probative evidence of record does not support a grant of service connection for prostate cancer, to include as a result of exposure to polyurethane paint in service. The "benefit-of-the-doubt" rule enunciated in 38 U.S.C.A. § 5107(b) is not applicable, as there is not an approximate balance of evidence. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). ORDER Entitlement to a disability evaluation in excess of 50 percent prior to September 13, 2010, for depressive disorder, NOS, and panic disorder with agoraphobia is denied. Entitlement to a disability evaluation of 100 percent from September 13, 2010 forward for depressive disorder, NOS, and panic disorder with agoraphobia is granted. Entitlement to a disability evaluation in excess of 30 percent prior to December 13, 2011, for chronic interstitial lung disease associated with reactive airway disease or asthma is denied. Entitlement to a disability evaluation in excess of 60 percent from December 13, 2011 forward for obstructive lung disease with mild centrilobular emphysema is denied. Entitlement to service connection for prostate cancer is denied. REMAND The Veteran contends that he is no longer employable as a result of his service-connected disabilities which consist of psychiatric and respiratory disorders and residuals of a right orchiectomy. There is some medical evidence on file that supports his contention. See January 2013 statement of VA psychiatrist (reflecting psychiatric and respiratory disabilities produces unemployability). He has therefore raised the issue of a total disability rating for compensation based on individual unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (once a veteran submits evidence of a medical disability and additionally submits evidence of unemployability, VA must consider a total rating for compensation based upon individual unemployability). The Court recently held that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). If the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted. Id at 455. The law provides that a TDIU may be granted upon a showing that the Veteran is unable to secure or follow a substantially-gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). In this case, the record demonstrates that the Veteran is currently unemployed. While the appellant has been afforded several VA examinations pursuant to his claims of increased evaluations, an opinion as to the effect of all of his service-connected disabilities on his employability has not been rendered. The Board therefore finds that the appellant should be afforded an appropriate VA examination to determine whether he is unable to secure or maintain substantially-gainful employment as a result of his service-connected depressive disorder, NOS, and panic disorder with agoraphobia, lung disease, or right orchiectomy. Although the Veteran is now in receipt of a 100 percent schedular rating based on his depressive and panic disorders with agoraphobia, this rating was made effective September 13, 2010, and it is unclear whether he may otherwise be entitled to a TDIU. Bradley v. Peake, 22 Vet. App. 380 (2008). VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008). Indeed, as noted in Bradley, VA must consider a TDIU claim despite the existence of a schedular total rating and award SMC under 38 U.S.C.A. § 1114(s) if VA finds the separate disability supports a TDIU independent of the other 100 percent disability rating. See Bradley, 22 Vet. App. 280, 294 (2008). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should obtain any VA records pertaining to treatment for the Veteran's depressive disorder, NOS, and panic disorder with agoraphobia, as well as for all other service-connected disabilities since 2011 and associate such with the claims folder or the electronic record via Virtual VA. Any negative reply must also be included in the claims folder. 2. Following completion of the above, the RO/AMC should then schedule the Veteran for an appropriate VA examination to determine the effect of all of his service-connected disabilities on his employability. The examiner should offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the appellant is unable to secure or maintain substantially-gainful employment solely as a result of his service-connected disabilities. The examination report must include a complete rationale for all opinions and conclusions expressed. 3. Thereafter, readjudicate the issue on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be provided with an SSOC and afforded the opportunity to respond thereto. The case should then be returned to the Board, if in order, for further appellate process. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs