Citation Nr: 1321506 Decision Date: 07/03/13 Archive Date: 07/12/13 DOCKET NO. 08-28 644 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an increased rating for essential tremor of the left (minor) hand, currently rated 10 percent disabling. 2. Entitlement to an increased rating for anxiety reaction, currently rated 10 percent disabling. 3. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU). ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION The Veteran served on active duty from September 1980 to September 1984. He was also a member of the Army Reserve. These matters come before the Board of Veterans' Appeals (Board) from a February 2008 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Columbia, South Carolina, that-in pertinent part, denied entitlement to increased ratings for the essential tremor of the left hand and anxiety reaction, and denied entitlement to a TDIU. In his September 2008 Substantive Appeal (VA Form 9), the Veteran requested a hearing before a Veterans Law Judge at the RO (Travel Board hearing). He subsequently withdrew his hearing request. In March 2011, the Board remanded the case to the RO, via the Appeals Management Center (AMC). The Veteran has a Virtual claims file, which is a highly secured paperless repository, associated with his appeal. The Board has reviewed the documents in the Virtual file and notes the non-duplicative documents in the Virtual file were reviewed and considered by the AMC/RO, as noted in the April 2013 Supplemental Statement of the Case (SSOC). Hence, there is no need to obtain a waiver from the Veteran or remand for RO review and consideration. See 38 C.F.R. § 20.1304 (2012). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The AMC/RO complied with the March 2011 Board remand by obtaining additional treatment records and arranging a VA examination. 2. The Veteran's left hand disability has been manifested throughout the appeal period by complaints of pain and tremor but no abnormal findings on examination. 3. Throughout the appeal period anxiety disorder has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 4. The Veteran's service-connected disabilities do not preclude him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The requirements for an evaluation higher than 10 percent for left (minor) hand disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.159, 3.321(b)(1), 3.655(b), 4.1, 4.10, 4.124a, Diagnostic Code (DC) 8515 (2012). 2. The requirements for an evaluation of 30 percent, but no higher, for anxiety reaction are met. 38 U.S.C.A. § 1155; 38 C.F.R. § 3.321(b)(1), 4.1, 4.6, 4.10, 4.130, DC 9400 (2012). 3. The requirements for a TDIU are not met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim. 38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2012). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Court Of Appeals For Veterans Claims has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Adequate VCAA notice in an increased rating claim required that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) evidence demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) vacated in part Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Prior to issuance of the rating decision on appeal, in a letter issued in June 2007, the RO notified the Veteran of the evidence needed to substantiate his claim for increased ratings and a TDIU. The letter also satisfied the second and third elements of the duty to notify by informing the Veteran that VA would try to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. The Board finds the June 2007 letter was time-and content-compliant. See 38 C.F.R. § 3.159(b); see also Dingess/Hartman, supra. Hence, the Board finds VA complied with the VCAA notice requirements. The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained available records of treatment reported by the Veteran and afforded him VA examinations. Further, the AMC fully complied with the additional development directed in the March 2011 Board remand. Neither the Veteran nor his representative asserts that there are additional records to be obtained. Hence, the Board finds VA complied with the duty to assist the Veteran with his claims, and there is no issue that precludes the Board from addressing the merits of the Veteran's appeal. See 38 C.F.R. § 3.159(c). Applicable Law and Regulation Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities 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 must also 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. VA must resolve any reasonable doubt regarding the degree of disability in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Where there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7, see also 38 C.F.R. § 4.21. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when either disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Analysis Left Hand By way of history, a February 1996 rating decision granted service connection for essential tremor of the left (non-dominant) hand with an initial 10 percent rating under 38 C.F.R. § 4.124a, DC 124a, effective in July 1988. VA received the Veteran's current claim for an increased rating in June 2007. The examination reports of record note the Veteran is right handed. DC 8515 rates symptomatology of the median nerve. DC 8615 rates neuritis of the same peripheral nerve. See 38 C.F.R. § 4.124a. Under these criteria, complete paralysis of the median nerve of the minor extremity warrants a 60 percent rating. 38 C.F.R. § 4.124a, DC 8515. Severe incomplete paralysis warrants a 40 percent rating; moderate incomplete paralysis 30 percent; and, mild incomplete paralysis, 10 percent. Id. The rating schedule provides guidance for rating neurologic disabilities. Cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The Veteran's VA outpatient records note his complaints of left upper extremity pain in April and May 2008. On a scale of one to 10, the Veteran assessed his pain as 9/10. He also reported a left thumb tremor. In March 2011, he reported the tremor was worsening. The noted findings on physical examination, however, relate to the left shoulder. In a January 2008 statement, PB, a friend, related that the Veteran and her late husband were friends, and the Veteran had lived with her over the prior four months. She reported the Veteran did not sleep very well due to left shoulder and left arm pain, and that the Veteran took medication for nerve damage. As a result, the Veteran had lost a lot of sensitivity. PB reported further that she rubbed the Veteran's left shoulder and left side with a topical analgesic cream. The remainder of the statement addressed what the Veteran told her about having been unemployed for 13 years. The March 2012 examination report reflects the examiner conducted a review of the claims file as part of the examination. The examiner noted brachial plexus neuropathy was diagnosed in 2003, but the supporting data for the diagnosis was meager. The Veteran reported a nerve conduction study (NCS)/ electromyography (EMG) conducted in 2003 was minimally abnormal. He reported his primary symptoms as moderate left upper extremity pain and a tremor. The examiner noted that no tremor was revealed by the examination. Physical examination revealed the Veteran's motor strength and grip as 5/5 throughout both upper extremities, and there was no muscle atrophy. Deep tendon reflexes were all 2+. The examination report reflects the examiner assessed all of the Veteran's peripheral nerves as normal. Although the Veteran reported the 2003 NCS/EMG was abnormal, the examiner assessed it as normal. The examiner noted that physical examination revealed left upper extremity give away weakness and sensory loss that did not follow any anatomic pattern. As a result, he opined there was no abnormality. No left arm tremor was present the day of the examination. The examiner noted the Veteran's records indicated that the tremor was thought to be the result of a thyroid dysfunction, though the Veteran was not under any treatment at the time of the examination. Thus, the examiner opined the tremor, as described, was not related to central or peripheral nerve dysfunction. The examiner requested an EMG to re-evaluate the possibility of a peripheral neuropathy or plexopathy. A May 2012 outpatient entry; however, notes the Veteran cancelled the test, and it was not rescheduled. Thus, information that may have been revealed by the study is not available for this appeal. In a March 2012 statement, the Veteran disputes the examiner's notation that no left arm tremor, which he described as an uncontrollable shaking of the thumb, was present. The Veteran asserts the tremor is present all of the time, and he in fact showed it to the examiner. As a trained medical professional, the Board infers that the examiner would know when observed. Further, the examiner did consider the Veteran's reports in the examination report, but opined the description of the tremor related to a thyroid issue rather than a peripheral nerve. No tremor was noted when the Veteran sought VA treatment from other medical professionals for pertinent complaints. Although the Veteran is competent to report a tremor and severe pain, pertinent symptoms have not been identified on examination or clinical evaluation. This is significant given the Veteran's report that these symptoms were always present. In light of the fact the objective findings on clinical examination revealed no abnormal findings, and no pertinent findings were reported when the Veteran sought treatment; the Board must conclude that the evidence weighs against an increased rating. 38 C.F.R. § 4.124a, DC 8515. The Board acknowledges PB's lay observations of the Veteran's left upper extremity symptoms. See 38 C.F.R. § 3.159(a)(2). Thus, the Board also considers the propriety of an increased rating for neuritis under DC 8615. See 38 C.F.R. § 4.124a. PB did not clearly describe whether the Veteran's primary pain was in the left shoulder or the left arm. As noted earlier, the VA outpatient records note the primary positive findings related to the left shoulder. Nonetheless, the 10 percent rating contemplates his pain complaints. The Veteran's reports of an ongoing tremor haven not been seen by medical providers and are not reported in the lay reports that he has submitted. His report of an ongoing tremor therefore is not deemed credible. As noted, motor strength, grip, and reflexes were all normal throughout the upper extremities. Hence, a higher rating for neuritis is not indicated. The evidence weighs against a rating in excess of the current 10 percent. Reasonable doubt does not arise and the claim is denied. 38 C.F.R. §§ 4.1, 4.10, 4.124a, DC 8515. Anxiety disorder Applicable Law and Regulation When evaluating a mental disability, 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 disability, 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. The symptoms recited in the criteria in the rating schedule for evaluating mental disabilities are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. A Veteran may only qualify for a given initial or increased rating based on mental disability (psychiatric disability) by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed.Cir.2013). Analysis A July 1996 rating decision granted service connection for anxiety reaction with an initial 10 percent rating, effective in July 1988. VA received the Veteran's current claim for an increased rating in June 2007. A 10 percent rating is warranted for anxiety disorder for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or, where the symptoms are controlled by continuous medication. 38 C.F.R. § 4.130, DC 9400. A 30 percent rating will be assigned for anxiety disorder when there is evidence 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 normal conversation), 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, and recent events). Id. A 50 percent evaluation will be assigned with evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation applies when a veteran's occupational and social impairment reflects 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned when there is 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; and memory loss for names of close relatives, own occupation, or own name. Id. The examiner did not have access to the claims file at the July 2007 VA examination, but he did seek to take a history from the Veteran. Further, the examiner requested and reviewed the claims file after the examination and provided an addendum in October 2007. The July 2007 examination report notes the Veteran reported he was not certain how he should answer the examiner's question of "what brought him to the examination?" He reported further that he was not sure when he had his last Compensation and Pension examination; although he thought he had received some treatment since his last examination. The Veteran denied receiving any mental health treatment at the time of the examination, but he may have been prescribed some medication for sleep problems one to two years earlier, which the Veteran said helped. The Veteran reported his medication ran out, and he did not obtain refills due to transportation problems. The Veteran reported he last worked in the mid-1990s for Sperry Rail, but had been fired after a year for incompetence and non-performance of duties. He had not worked since due to his left arm disability and his anxiety, and he received Social Security (SSA) disability based on those disabilities as well as a personality disability. The Board notes the related Social Security records show no disability was diagnosed. A June 2005 private evaluation related to the SSA claim reflects Axis I diagnoses of history of alcohol abuse and history of cannabis abuse. A personality disability not otherwise specified with antisocial and passive-aggressive features was noted in Axis II. The Veteran reported a history of alcohol abuse but said he had last drunk five years earlier. He denied having used marijuana or other illicit drugs for over five years. The Veteran reported he lived with his mother who took care of him. He was single with no children, was not dating, but had a close friend he saw weekly when she came to visit. He also reported two casual friends whom he saw every two to three months when they visited. The Veteran reported he watched TV and rested, and denied having any hobbies or activities. Mental status examination revealed the Veteran as alert and generally oriented and attentive. His mood appeared to be a bit anxious, and his affect was constricted and a bit mildly anxious. The Veteran's speech was at a regular rate and rhythm. There was some mild evidence of psychomotor agitation, poor eye contact, and the Veteran's response to questions was very vague. The Veteran demonstrated decreased motivation with things it seemed he should have been able to remember. He often said he did not know or he did not remember. The examiner noted that it was not clear if the Veteran's vagueness was due possibly to a schizoid personality disability, decreased motivation, or the Veteran just did not want to cooperate with the examiner. In any event, the examiner noted the Veteran really lacked insight into his current condition. The Veteran denied any history of suicide attempts or any current thoughts of hurting himself or others. He reported that the last time he was aggressive with someone was a week earlier with his brother. The Veteran also denied hearing voices, except sometimes he heard and saw things in his dreams. The examiner noted the Veteran's thought process was logical and coherent, but there was impoverishment in terms of thought content. The Veteran's memory was severely impaired for immediate information, and he had difficulties with recent and remote events as well. He was not able to concentrate well enough to spell "world" backwards, nor was he able to interpret a Proverb. The examiner estimated the Veteran's intelligence as in the low-average to average range, and the Veteran had limited insight into his current condition. The examiner rendered Axis I diagnoses of generalized anxiety disorder and alcohol abuse in remission. Axis V, global assessment of functioning (GAF) was assigned as 54 for the anxiety disorder. The examiner also noted the Veteran required help managing his benefits. The GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disabilities (4th ed.1994) (DSM-IV). The Board notes that a GAF of 54 is in the range of 51 to 60, and is indicative of moderate symptoms. Upon receipt of the examination report, the RO provided the claims file to the examiner for review. The examiner noted the Veteran reported moderate to considerable symptoms associated with his anxiety: ongoing fear and anxiety; mistrust of people's motives, he felt people had ill intent towards him; and, he reported he slept three to four hours. The Veteran also reported muscle tension at times, and he irritated easily. He also reported a sense of restlessness and agitation. The Veteran reported his symptoms did not impact his activities of daily living. The examiner noted the Veteran's general adaptability and interaction with others appeared to be moderately to severely impacted due to his anxiety, but the examiner was also concerned about the prospect of other pathology playing a role in making the Veteran's social problems worse-such as a personality disability. The examiner rendered the same assessment of impairment of the Veteran's occupational impairment. The examiner noted a review of the claims file would assist him in resolving those questions. The October 2007 addendum reflects the Veteran was also present with the examiner reviewed the claims file. Based on the examiner's review of the claims file and his interview of the Veteran, he noted he desired to change his July 2007 evaluation. The examiner noted a 1994 assessment of the Veteran where the examiner diagnosed an avoidant personality problem based on the fact the Veteran seemed hostile, suspicious, and some mood disturbance. The examiner observed that another October 1994 entry noted anxiety, feelings of inadequacy, and an avoidant style with suspiciousness. The examiner also noted a prior assessment by a Board of two examiners, where he was one of the clinicians, and the assessment was that there did not appear to be evidence of an Axis I diagnosis. The examiner noted the Veteran reported he drank five days a week, whereas at the July examination the Veteran denied having used alcohol for some time. As a result, the examiner noted that, although the Veteran's reported symptoms seemed consistent with an anxiety disorder, they also could be substance-induced. The examiner concluded that the Veteran's responses at the October 2007 visit led him to conclude the Veteran was dishonest at the July 2007 examination. As a result, the examiner noted he changed his Axis I diagnosis to reflect only alcohol dependence. The GAF score remained at 54. The examiner noted that, despite the history of the prior noted assessments that suggested a personality disability, he decline to enter that diagnosis in Axis II. An October 2007 VA outpatient entry notes the Veteran reported he had difficulty maintaining relations with others, and he preferred being alone. As noted in the earlier discussion of the Veteran's left arm, PB noted the Veteran had trouble sleeping, though she attributed it primarily to left upper extremity pain. She also related that the Veteran did not drink alcohol. The Veteran submitted statements from other friends attesting that he was not a current user of alcohol. A February 2008 VA mental health outpatient entry notes the Veteran admitted to alcohol use in October 2007. He denied any suicidal or homicidal thoughts or hallucinations. The Veteran appeared anxious, but declined any services. Other VA outpatient entries, such as in November 2010, noted the Veteran's denial of alcohol consumption over a considerable period of time. As a result, the Board remanded the case in March 2011 for another examination. The February 2012 Disability Benefits Questionnaire reflects the examiner conducted a review of the claims file as part of the examination. The Veteran reported he lived with his girl friend who helped him financially. He denied any change in his mental health treatment status since the last examination, and he reported he received sleep medication from his primary care physician. The Veteran also reported eight years of continuous sobriety from both alcohol and cannabis. The examiner noted the Veteran reported anxiety, suspiciousness, and chronic sleep impairment. The examiner also noted reports of excessive worry, mild rumination, insomnia, and feeling tense and edgy. The Veteran denied any suicide or homicide ideation. The examiner noted he saw no evidence of memory impairment at the examination and opined the Veteran was capable of managing his financial affairs. The examiner assessed an Axis V GAF 55; but checked a box indicating that the Veteran's current level of functioning was manifested by mild or transient symptoms that resulted in decreased efficiency only during periods of significant stress. The Board first notes that the examiner was in fact accurate about what the available records related to the Veteran noted about his reported alcohol consumption. The only reasonable inference is that the Veteran can be an inconsistent, if not a deceptive, historian. The Board finds the Veteran has not been prejudiced, as the examiner in fact diagnosed the Veteran as having objective symptoms of anxiety. The Board also notes the fact the evidence of record indicates the Veteran has not deemed his symptomatology sufficiently significant so as to avail himself of treatment. In fact, as noted earlier, he denied referral for services in April 2008. His outpatient records related to all of his diagnosed disabilities consistently report his denial of suicide or homicide thoughts, hallucinations, or other significant symptoms. The symptoms most consistently noted, as shown by the examiner at the July and October 2007 assessments, are anxiety and sleep impairment. The July 2007 examination is the only indication of reported memory and concentration impairment, which was due to the Veteran's apparent lack of motivation to respond to the questions. Although the examiner checked a box on the February 2012 examination report indicating that the Veteran's symptoms were of mild severity, he assigned GAF contemplating moderate symptoms. The totality of the evidence shows the Veteran's reports of chronic sleep impairment and anxiety have been consistent, as noted in his outpatient records. Hence, the Board finds him credible to that extent. As a result, the Board resolves any doubt in his favor and finds a 30-percent rating was more nearly approximated as of the time of the July 2007 examination. 38 C.F.R. § 4.7. The Board finds a higher, 50 percent, rating was not met or approximated, as the examiner did not note any findings of significant symptoms of the 50 percent criteria such as panic attacks or mood disturbance, etc. As just discussed, the Board finds further that the preponderance of the evidence shows the Veteran's anxiety disorder has more nearly approximated the assigned 30 percent rating for the entire rating period on appeal, and there is no factual basis for a staged rating for any part of the rating period on appeal. 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.130, DC 9400. Extraschedular Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2008). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The evidence of record also shows the rating criteria for both the left arm disability and an acquired mental disability describe each of the Veteran's disabilities and its severity, as discussed above. The left hand disability is manifested by possible pain, which is specifically contemplated in the rating criteria. The rating for the anxiety reaction encompasses all social and occupational impairment from the disability. Hence, the Board finds the rating criteria for each disability anticipates the Veteran's left arm disability and the generalized anxiety disorder disability. Thus, the scheduler criteria are adequate to address each of his disabilities, which means neither of the Veteran's disabilities is exceptional. In the absence of an exceptional disability picture, there is no factual basis for referral for a higher rating on an extraschedular basis of either disability. See Johnson v. Shinseki, --Vet. App.--, 2013 WL 1224810 ( March 27, 2013, No. 10-1785) (disabilities are not considered for extraschedular referral on a cumulative basis). Nonetheless, the Board has considered all of the Veteran's symptoms under the applicable rating criteria. Thus, consideration on a cumulative basis does not reveal an exceptional disability picture. See 38 C.F.R. § 3.321(b)(1); see also Thun v. Peake, 22 Vet. App. 111 (2008). TDIU The Veteran asserts he is unable to obtain and maintain substantially gainful employment due to his service-connected disabilities. Applicable Law and Regulations A TDIU may be assigned where the combined schedular rating for the service-connected disabilities is less than 100 percent, when it is found that the service-connected disabilities render the Veteran unable to secure or follow a substantially gainful occupation. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. Age or intercurrent non-service-connected disability may not be considered in determining entitlement to a total compensation rating. 38 C.F.R. § 4.19. Factors to be considered are the Veteran's employment history and his educational and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). Under 38 C.F.R. § 4.16(a), if there is only one service-connected disability, the disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. VA policy is; however, to grant TDIU in all cases where a Veteran is unable to work dud to service connected disability. Rating boards are required to submit to the Director, Compensation and Pension Service (Director), for extraschedular consideration, all cases of veterans who are unemployable by reason of service-connected disability(ies), but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). 38 C.F.R. § 4.16(b). Where a claimant does not meet the schedular requirements of 38 C.F.R. § 4.16(a), the Board has no authority to assign a total disability evaluation based on individual unemployability under 38 C.F.R. § 4.16(b). Bowling v. Principi, 15 Vet. App. 1, 10 (2001). The Board may, however, refer the claim to the Director for extraschedular consideration. The governing norm for the Board in making the determination is whether there is a plausible basis for concluding that the Veteran is unable to secure and follow a gainful occupation. Bowling, 15 Vet. App. at 9-10. When evaluating a claim for a TDIU, the central inquiry is whether the Veteran's service-connected disabilities, alone, are of sufficient severity to produce unemployability. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). As noted, consideration may not be given to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In essence, the unemployability question, that is, the Veteran's ability or inability to engage in substantial gainful activity, has to be looked at in a practical manner, and that the thrust is whether a particular job is realistically within the capabilities, both physical and mental, of a claimant. See Moore v. Derwinski, 1 Vet. App. 83 (1991). Marginal employment shall not be considered substantially gainful employment, and generally shall be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis, when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). See Faust v. West, 13 Vet. App. 342 (2000). The VA General Counsel has concluded that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by such circumstances. Thus, the criteria include a subjective standard. It was also determined that "Unemployability" is synonymous with the inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91 (1991). In determining whether a veteran is entitled to individual unemployability, neither his nonservice-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. at 361. Thus, in deciding the claim, the Board may not favorably consider the effects of the Veteran's nonservice-connected disabilities with respect to their degree of interference with the Veteran's employability. Indeed, the Court stated that in order for a veteran to prevail on a claim for a total compensation rating based on individual unemployability, the record must reflect some factor that takes his case outside of the norm. If total industrial impairment has not been shown, the VA is not obligated to show that a veteran is incapable of performing specific jobs in considering a claim for a total rating based on individual unemployability. See Gary v. Brown, 7 Vet. App. 229 (1994). Analysis Service connection is in effect solely for the Veteran's left arm disability and his generalized anxiety disorder, both of which are discussed above. When the increase allowed by the Board in the decision above for the anxiety disorder is considered, the Veteran's total combined rating is 40 percent. See 38 C.F.R. § 4.25, Table 1 (2012). Thus, the Veteran does not meet the percentage requirements for consideration of a TDIU on a schedular basis. 38 C.F.R. § 4.16(a). The question remains whether the Veteran's service-connected disabilities, regardless of age, prevents him from securing and following substantially gainful employment per 38 C.F.R. § 4.16(b). The Veteran's VA Form 21-8940 reflects he is a high school graduate, and completed two years of college. He noted further on the form that he last worked full time in 1984, and became too disabled to work in 1988. He asserts further that he has difficulty relating to others as a result of his anxiety disorder. As concerns the Veteran's lay assertions, the Board finds his credibility doubtful. The respective examination reports reflect that both the examiner of the Veteran's left arm and the psychologist examiner opined the Veteran's disability did not render him unemployable. Indeed, the left arm examiner assessed no occupational impact at all. The psychologist assessed the Veteran's occupational impairment as mild, and specifically noted the Veteran was not unemployable. The assessed GAF in the mid-50s is reflective of an ability to work. Inasmuch as the left arm disability is causing no observable impairment and the psychiatric disability is no more than moderate and does not prevent gainful employment, the disabilities in combination would not preclude gainful employment for which the Veteran would otherwise be qualified. In light of the above, the Board is constrained to find the preponderance of the evidence shows the Veteran's service-connected left arm disability and generalized anxiety disorder do not render him unable to secure and follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Board finds further that the evidence shows no plausible basis for referring the Veteran's claim for consideration by the Director for unemployability on an extraschedular basis. 38 C.F.R. § 4.16(b). Thus, the Board is constrained to deny the claim. In reaching this decision the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the Veteran's claims, however, the doctrine is not for application. Schoolman v. West, 12 Vet. App. 307, 311 (1999). ORDER Entitlement to an increased rating for left arm disability is denied. Entitlement to an evaluation not to exceed 30 percent for anxiety reaction is granted. Entitlement to a TDIU is denied. ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs