Citation Nr: 1321478 Decision Date: 07/03/13 Archive Date: 07/12/13 DOCKET NO. 09-47 230 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to the service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to an initial disability rating in excess of 30 percent for the service-connected PTSD. ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran served on active duty from July 1967 to May 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the Department of Veteran's Affairs (VA) Regional Office (RO) in San Diego, California. During the pendency of the appeal, jurisdiction of the claim was transferred to the Oakland RO. In September 2012, the Board denied the claim of service connection for left ear hearing loss and thus, the matter is no longer in appellate status. The same decision also remanded the claims of service connection for hypertension and increased initial evaluation for the service-connected PTSD for further development and adjudication. The claims have been returned to the Board and are now ready for appellate disposition. The Veteran has raised claims of entitlement to service connection for skin and eye conditions. See statement received in November 2012. These matters have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The competent and probative medical evidence of record preponderates against a finding that the Veteran's hypertension is due to events in active service, manifested to a compensable degree within one year after the Veteran's separation from service in May 1970, or is proximately due to, the result of, or aggravated by the service-connected PTSD. 2. Throughout the appellate period, the Veteran's PTSD has not shown to be productive of: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment in short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); or impaired abstract thinking. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for the assignment of an initial evaluation in excess of 30 percent for the service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.130, including Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the Veteran pre-adjudication notice by letter dated in May 2008. The RO sent an additional notice letter to the Veteran in October 2012, which pertained to the claim for hypertension, to include on a secondary causation basis. The claim was subsequently readjudicated in a February 2013 supplemental statement of the case. Mayfield, 444 F.3d at 1333. The claim pertaining to PTSD arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for PTSD. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. VA also has a duty to assist the Veteran in the development of the claims, which is not abrogated by the granting of service connection. VA has obtained service treatment records, assisted the Veteran in obtaining evidence, provided the Veteran VA examinations, and afforded the Veteran the opportunity to give testimony before the Board, which he declined. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. II. Analysis The Board has reviewed all the evidence in the Veteran's paper claims file and Virtual VA record, which contains VA treatment records considered by the RO. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Hypertension Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some 'chronic diseases,' such as hypertension, presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With 'chronic disease' shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term 'chronic disease', whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. 38 C.F.R. § 3.310. The Board has considered all lay and medical evidence as it pertains to the issues. 38 U.S.C.A. §§ 5107(b), 7104(a); 38 C.F.R. § 3.303(a). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). In statements, the Veteran claims that he has hypertension as a result of his service-connected PTSD. Specifically, he contends that his PTSD symptoms exacerbate his hypertension when he becomes anxious or angry. In his November 2008 notice of disagreement, the Veteran alternatively contended that he had borderline high blood pressure in service, which has remained high to this date. Turning first to direct service connection, the service treatment records reflect no histories, findings, or treatment suggestive of hypertension. While a blood pressure reading of 144/92 was recorded at separation examination in April 1970, the Veteran was not diagnosed with high blood pressure. Post-service, hypertension was first documented in 2008, clearly outside the one-year presumptive period. 38 C.F.R. § 3.307, 3.309. Outpatient treatment records dated between 2009 and 2013 show continued treatment for hypertension, stable on medication. The Veteran was afforded a VA examination in December 2012. The Veteran was taking Losartan with good results. The Veteran felt his hypertension was caused by stress associated with PTSD. The examiner first opined hypertension was less likely than not incurred in or caused by an in-service, injury, event, or illness. The examiner reasoned that there was no evidence of hypertension during service or a diagnosis of hypertension from the blood pressure readings taken during service. The examiner opined hypertension developed after the Veteran was discharged from the service. The examiner also opined hypertension was not aggravated by his PTSD. The examiner reasoned that the Mayo Clinic stated that for most adults, there was no identifiable cause of essential hypertension. The Veteran had multiple risk factors for hypertension including advanced age, obesity, sedentary lifestyle, alcohol abuse, and stress. Though stress and PTSD was a risk factor for hypertension, the Veteran had other more prominent risk factors delineated above. The examiner also noted the Veteran had PTSD for many years and his hypertension according to the claims file was diagnosed in 2008 and it was not evident from the claims file that PTSD worsened or aggravated his essential hypertension. Hypertension is considered a chronic disease and thus, consideration under 38 C.F.R. § 3.303(b) is warranted. Where a combination of manifestations sufficient to identify a 'chronic disease' in service, and establish chronicity at the time are present, any later manifestation of the same 'chronic disease' is subject to service connection unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. As noted above, hypertension was not diagnosed during service and the first objective findings in 2008 dates 38 years after separation. The long time lapse can be considered, along with other factors, as evidence of whether an injury or disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Veteran is competent to report such complaints associated with high blood pressure like dull headaches, dizziness, and nosebleeds. The Veteran is not, however, competent to report whether these complaints were manifestations of a 'chronic disease.' See Jandreau, supra. As outlined above, the competent medical evidence of record concludes that hypertension is not related to service. The 'chronic disease' was not present to a degree capable of identifying the disease entity during service. No symptoms related to hypertension have been identified in the post-service medical record for continuity of symptomatology. The Board concludes that service connection for hypertension is not warranted under 38 C.F.R. § 3.303(b). Nevertheless, service connection may also be granted when the evidence establishes a nexus between active duty service and current complaints. The Board finds that the preponderance of the competent evidence is against a finding of a nexus between the Veteran's hypertension and his active service, despite his contentions to the contrary, i.e. that he was borderline hypertensive at discharge. In that regard, the Board finds substantially probative the December 2012 opinion that hypertension was less likely than not incurred in or caused by an in-service, injury, event, or illness. The examiner reasoned that there was no evidence of hypertension during service or a diagnosis of hypertension from the blood pressure readings taken during service. The examiner opined hypertension developed after the Veteran was discharged from the service. The examiner also opined hypertension was not aggravated by his PTSD. This opinion was rendered after review of the Veteran's claims file, including his service treatment records, and physical examination of the Veteran; the opinions are clearly based on an accurate history. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (finding that a physician's access to the claims file and the thoroughness and detail of the opinion are important factors in assessing the probative value of a medical opinion). The only evidence of record to support the Veteran's contentions is his statements. His statements do not establish a nexus between any acquired pathology and his military service or a service-connected disability. Although lay evidence is acceptable to prove the occurrence of an injury during active duty or symptomatology over a period of time when such symptomatology is within the purview of or may be readily recognized by lay persons, lay testimony is not competent to prove a matter requiring medical expertise. With regard to hypertension, it requires specialized training for a determination as to diagnosis and causation and is not susceptible of lay opinions on etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Therefore, the Board cannot give decisive probative weight to the opinions of the Veteran about the origins of his hypertension because he is not qualified to offer such opinions. In short, service connection is not warranted on a direct, presumptive or secondary basis for the claimed hypertension. Though the Veteran contends that he has hypertension that is related to his service-connected PTSD, there is no medical evidence on file supporting the Veteran's assertion, and his statements do not constitute competent evidence of a medical nexus opinion. Therefore, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hypertension, and thus, the benefit-of-the-doubt doctrine does not apply. As such, the evidence is insufficient to support a grant of service connection for any such hypertension. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation at any stage since the effective date of service connection. See Fenderson v. West, 12 Vet. App 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. The service-connected PTSD disability has been assigned an initial 30 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the applicable criteria, a 30 percent disability evaluation is warranted for 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). 38 C.F.R. § 4.130. A 50 percent disability evaluation is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment in short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board's "primary consideration" is the Veteran's symptoms, but it must also make findings as to "how those symptoms impact[ ]" the Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); see Mauerhan v. Principi, 16 Vet. App. 436 (2002). Because "use of the term 'such as' [in the rating criteria] demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list," "any suggestion that the Board was required, in complying with the regulation, to find the presence of all, most, or even some, of the enumerated symptoms is unsupported by a reading of the plain language of the regulation." Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed.Cir.2004). However, because "[a]ll non-zero disability levels [in § 4.130] are also associated with objectively observable symptomatology" and the plain language of the regulation makes it clear that "the Veteran's impairment must be 'due to' those symptoms," "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio, 713 F.3d at 112. The Veteran contends that he is entitled to an initial evaluation in excess of 30 percent for the service-connected PTSD. Specifically he maintains that he suffers from symptoms to include, but not limited to, nightmares, interrupting thoughts about war, loss of sleep, social isolation, memory problems, lack of interest in activities, flashbacks, lack of concentration, hyperstartle response, and performing perimeter checks of his home each night. See claim filed in November 2007. In his substantive appeal, the Veteran contends that he suffered from short term memory problems, but he bought software to help with this problem. He claimed that he thought about suicide a number of times, but he did not consider it an option as he could not fail his family and they would not get his life insurance. He indicated that he did not have any friends. He stated that he would have excelled at work and become a project manager or engineering manager but for his PTSD. He also reported body jerking during his sleep caused by nightmares. He additionally claimed that he turned to alcohol to alleviate his symptoms and was not a good father to his children. He requested a 70 percent rating. Having carefully considered all the evidence of record in light of the pertinent law and regulations, the Board finds that an initial evaluation in excess of 30 percent is not warranted. 38 C.F.R. § 4.7. The pertinent evidence is as follows. Upon VA examination in June 2008, the Veteran complained of nightmares and intrusive thoughts. He indicated he avoided talking about Vietnam to other people and avoided watching war movies. He had some friendships, but did not initiate get togethers. He engaged in more solitary activities like golf or hiking. He reported loss of sleep and difficulty with anger control. He was hypervigilant and bothered by loud noises. He had been married for 41 years. He had been at his job as an engineer for 25 years. He denied any significant problems at work. The Veteran was dressed casually. His affect was appropriate to context. His speech was spontaneous. There was no loosening of associations or flight of ideation. The Veteran reported intrusive thoughts about Vietnam, but denied hallucinations. He was not delusional. He denied any suicidal ideation. Insight and judgment were fair. He was oriented in all spheres and both short and long term memory were intact. He was assigned a Global Assessment of Functioning Scale Score (GAF) of 55, which according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV), was indicative of moderate symptoms. VA outpatient treatment records dated in November 2009 show the Veteran reported nightmares and depression. He claimed his symptoms had gotten worse over the past 10 years. He endorsed nightmares two to three times per week and occasional flashbacks triggered by helicopter sounds, the smell of diesel fuel and humidity. He avoided watching war movies. He complained of being easily startled by people coming up behind him. He had survivor guilt. He complained of difficulty with sleep. The Veteran was well-groomed and had good eye contact. His speech was appropriate and of normal rate and volume. His mood was dysphoric and anxious. His affect was mildly blunted. Thought process was linear. There was no evidence of suicidal ideation, homicidal ideation or psychosis. Insight and judgment were fair to good. Cognition was grossly intact. He was assigned a GAF of 60, for moderate symptoms. In February 2010, there was no improvement in mood. In July 2010, the Veteran denied suicidal or homicidal ideation. His speech was logical. There was no sign of delusions or dangerousness. VA outpatient treatment records dated in 2010 and 2011 contain continued complaints of nightmares, guilt, and being quick to anger. Insight and judgment were fair. The Veteran denied suicidal and homicidal ideation. There was no evidence of memory impairment. In November 2010, the Veteran's sleep was better. His affect was full. There was no evidence of psychotic symptoms. The Veteran was assigned GAF scores of 54 and 58 showing moderate symptoms. In March 2011, the Veteran denied hyperarousal or avoidant behaviors. Speech was normal. Affect was full. Nightmares were down to two per week. In June 2012, the Veteran indicated he had suicidal thoughts on a number of occasions, but never acted on them. He worked 30 years as an engineer. He was alert and well-oriented. He denied current suicidal ideation. His thoughts were goal directed. His memory was intact, judgment was fair and insight was present. He was assigned a GAF of 70 for only mild symptoms, but generally functioning pretty well and having some meaningful interpersonal relationships. The Veteran continued to deny hallucinations, suicidal ideation, and homicidal ideation in September 2012. He was well oriented. His affect was appropriate. Memory was intact. Judgment was fair and insight was present. His GAF scores ranged from 55 to 60 for moderate symptoms. In November 2012, the Veteran indicated he was retiring at the end of the month. He was oriented in all spheres. His mood was congruent with affect. He denied suicidal and homicidal ideation. In December 2012, the Veteran's memory was intact. He again denied suicidal ideation. His thoughts were goal directed. He was assigned a GAF of 60 for moderate symptoms. In January 2013, the Veteran had some depressed mood, but he was oriented in all spheres. Upon VA examination in December 2012, the Veteran informed the examiner he was retired. He lacked the capacity to fill his time during retirement so there was mild worsening of his PTSD symptoms. The examiner noted the Veteran used alcohol to improve sleep onset and sleep duration. The examiner noted occupational and social impairment with reduced reliability and productivity. Since retirement, the Veteran reported increased withdrawal from other people, nightmares three times a week, claustrophobia, anxiety attacks, and no friends. He had no relevant legal or behavioral history. He admitted to four beers per day. He had recurrent distressing dreams of Vietnam, avoidance behavior, marked diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted range of affect, difficulty falling asleep, irritability, difficulty concentrating, and exaggerated startle response. The Veteran had a depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances. The Veteran did not have suicidal ideation, obsessional rituals, impaired impulse control, grossly inappropriate behavior, spatial disorientation, delusions or hallucination, neglect of personal hygiene, inability to perform activities of daily living, disorientation to time or place, persistent danger of hurting self or others, impaired judgment, impaired abstract thinking, gross impairment in thought process or communication, disturbances of motivation or mood, circumstantial, circumlocutory or stereotyped speech, difficulty understanding complex command, memory impairment, or near continuous panic or depression affecting his ability to function. Physical examination showed him to be casually dressed. His speech was fluent and spontaneous. He was goal directed. His affect was broad. Mood was mildly depressed. There was no abnormal thoughts or hallucinations or delusions. He was oriented times three. Insight and judgment were good. In sum, based on the evidence delineated above, there has been no objective evidence of: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment in short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); or impaired abstract thinking. The December 2012 VA examiner characterized the Veteran's level of occupational and social impairment as resulting in reduced reliability and productivity and some of the symptoms experienced by the Veteran (reported disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships) approximate those listed in the 50 percent criteria; however, the Board finds that, overall, the symptoms experienced by the Veteran are of similar duration, frequency, and severity as those described for the 30 percent rating, for the entire appeal period. It is clear that overall, the GAF scores assigned by VA, ranging from 54 (moderate symptoms) to 70 (mild symptoms), regarding the severity of his symptoms, paint a disability picture more consistent with PTSD productive of 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) found in the 30 percent rating criteria. 38 C.F.R. § 4.119; See Fenderson, 12 Vet. App. at 126. Finally, the Board has considered whether extraschedular consideration is warranted. The symptoms and resulting impairment demonstrated with regard to the PTSD disability falls within the schedular criteria. The Veteran's disability is manifested by impairment in social and occupational functioning. The rating criteria contemplate these impairments; hence, referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). A total rating for compensation based on individual unemployability (TDIU) is an element of all appeals of an initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to TDIU is raised where a Veteran : (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). However, TDIU is not raised in an increased rating claim unless the Roberson requirements are met. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). The evidence of record shows the Veteran continued to work for 30 years as an engineer until to his retirement with no significant interference from his PTSD. See June 2008 VA examination. He has not made any assertions of unemployability during the appeal period. Hence, further consideration of TDIU is not warranted. ORDER Entitlement to service connection for hypertension, to include as secondary to the service-connected PTSD, is denied. Entitlement to an initial disability rating in excess of 30 percent for the service-connected PTSD is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs