Citation Nr: 1322815 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 04-43 010 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a skin rash. 2. Entitlement to service connection for paresthesias. 3. Entitlement to service connection for erectile dysfunction, claimed as impotence, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and diabetes mellitus. 4. Entitlement to an initial disability rating for PTSD in excess of 10 percent. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD David Gratz, Counsel INTRODUCTION The Veteran had active service from January 1969 to August 1970. He served in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2005 and May 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In January 2013, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the claims file. At the hearing the Board indicated that it was not clear which issues were properly before it. This is clarified below. The record shows the Board remanded the issues of entitlement to service connection for a chronic obstructive pulmonary disorder, claimed as an upper respiratory disorder, and entitlement to service connection for peripheral neuropathy of the upper extremities in November 2008. Following development conducted pursuant to the Board's November 2008 remand, the RO granted service connection for those disorders in a March 2009 rating decision and a May 2010 rating actions, respectively. As such are complete grants of those benefits sought on appeal, those issues are no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). The Board notes that the RO's May 2010 supplemental statement of the case contains language indicating it had both granted service connection for peripheral neuropathy of the left and right upper extremities, and that that it had denied service connection for peripheral neuropathy of the upper extremities. This confusing language was re-stated in both the February 2012 and April 2012 supplemental statements of the case. Notwithstanding those ostensible denials, the Veteran continues to receive 10 percent disability ratings for peripheral neuropathy (PN) of each upper extremity. In correspondence dated June 2013, the Veteran's representative noted that "it is not clear why the RO continued to list service connection for PN as an issue when it was granted locally." The Board agrees; as the issues of entitlement to service connection for peripheral neuropathy of the left and right upper extremities have already been granted in the May 2010 rating action, no further supplemental statements of the case as to those issues were warranted. The Board also notes that the Veteran was granted service connection for diabetes mellitus in a March 2009 rating decision, and that rating was continued in a May 2010 rating decision which was apparently issued because the Veteran was provided with a new examination as to the severity thereof. The Veteran was also granted service connection for peripheral neuropathy of the lower extremities in a May 2010 rating decision. Finally, the Veteran was denied service connection for alcohol dependence in rating decisions dated March 2009 and April 2012; the Veteran did not file a timely notice of disagreement as to these rating decisions. As such, the issues of entitlement to service connection for diabetes mellitus, entitlement to service connection for peripheral neuropathy of the lower extremities, and entitlement to service connection for alcohol dependence are not before the Board. FINDINGS OF FACT 1. At his January 17, 2013 Board hearing, and in written correspondence from his representative dated June 3, 2013, both prior to the promulgation of a decision in the appeal, the Veteran notified the Board that a withdrawal of his appeal of the issue of entitlement to service connection for a skin rash is requested. 2. In written correspondence from his representative dated June 3, 2013, prior to the promulgation of a decision in the appeal, the Veteran notified the Board that a withdrawal of his appeal of the issue of entitlement to service connection for paresthesias is requested. 3. The most probative evidence fails to link the Veteran's erectile dysfunction to active service, or to his service-connected PTSD or diabetes. 4. The Veteran's PTSD symptoms have resulted in flashbacks; difficulty sleeping; nightmares; irritability; depression; a blunt affect; some startle response with loud noises; avoidance behavior, including of restaurants and crowds; anxiety attacks, especially when driving; hopelessness; helplessness; intrusive memories; recurrent dreams; intense psychological distress in response to internal or external cues; physical symptoms in response to internal or external cues; efforts to avoid thoughts, feelings, or conversations related to the trauma; efforts to avoid activities, places, and people that remind him of the trauma; diminished interest or participation in significant activities; feeling detachment from others; difficulty concentrating; hypervigilance; and paranoia. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal of the issue of entitlement to service connection for a skin rash by the appellant have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. The criteria for withdrawal of an appeal of the issue of entitlement to service connection for paresthesias by the appellant have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 3. The criteria for service connection for erectile dysfunction, including as secondary to service-connected PTSD and diabetes, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 4. The criteria for an initial 30 percent disability evaluation, and no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist With respect to the issues of entitlement to service connection for a skin rash and entitlement to service connection for paresthesias, the Board dismisses those claims because the Veteran has withdrawn those issues. As such, no discussion of VA's duty to notify and assist regarding those issues is necessary. Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004). This notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). With respect to the issue of entitlement to service connection for erectile dysfunction, VA's notice requirements were satisfied by an April 2005 letter which advised the Veteran of the criteria for establishing service connection, and which was sent prior to the initial adjudication of the Veteran's claim in August 2005. VA also provided the Veteran with notice regarding the assignment of disability ratings and effective dates in a March 2006 letter, after which the RO readjudicated the Veteran's claim in a May 2007 statement of the case. With respect to the issue of entitlement to an initial rating in excess of 10 percent for PTSD, VA has met its duty to notify for this claim. Service connection for that issue was granted in a May 2010 rating decision. The Veteran is now appealing the downstream issue of the initial rating that was assigned. Therefore, additional notice under the Veterans Claims Assistance Act of 2000 (VCAA) is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1131 (Fed. Cir. 2007), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Next, VA has a duty to assist the Veteran in the development of his claim. This duty includes assisting him in the procurement of pertinent medical records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the RO has obtained and associated with the claims file the Veteran's service treatment and personnel records and records of his post-service VA treatment. VA obtained two medical opinions from VA examiners regarding the Veteran's claimed erectile dysfunction, in May 2009 and March 2010. The May 2009 opinion report is adequate because the examiner based her opinion upon consideration of the Veteran's prior medical history, described the disability in sufficient detail so that the Board's evaluation of the claimed disability will be fully informed, and supported her conclusion with an analysis that the Board could consider and weigh against contrary opinions. Additionally, the VA examiner fully described the functional effects caused by the Veteran's erectile dysfunction. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). The Board has considered, and accepted, the Veteran's representative's June 2013 argument that the March 2010 VA examination is inadequate because it contains no rationale; however, no new examination is required because the May 2009 examination includes an adequate opinion and rationale. VA obtained two medical opinions from VA examiners regarding the Veteran's service-connected PTSD, in April 2009 and August 2011. Both opinion reports are adequate because the examiners based their opinions upon consideration of the Veteran's prior medical history, described the disability in sufficient detail so that the Board's evaluation of the claimed disability will be fully informed, and supported their conclusions with analyses that the Board could consider and weigh against contrary opinions. Additionally, the VA examiners fully described the functional effects caused by the Veteran's PTSD. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). The record reflects substantial compliance with the Board's prior remand instructions. In November 2008, the Board requested that the agency of original jurisdiction (AOJ) provide the Veteran with examinations as to his claimed erectile dysfunction and PTSD. As discussed above, the Veteran was provided with adequate examinations of those disorders in April 2009, May 2009, and August 2011. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions, and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Veteran has been afforded a hearing before a VLJ in which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ asked specific questions directed at identifying whether the Veteran had symptoms meeting the criteria for service connection and a higher initial rating, respectively. The VLJ did not specifically seek to identify any pertinent evidence not currently associated with the claims. This was not necessary, however, because the Veteran volunteered his treatment history and symptoms since service. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). For the foregoing reasons, the Board concludes that VA made all reasonable efforts to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. Withdrawal of Claims for Service Connection for Skin Rash and Paresthesias The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2012). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. Here, the Veteran has withdrawn his appeal of the issue of entitlement to service connection for a skin rash. Specifically, at his January 17, 2013 videoconference hearing, the Veteran stated that "I just withdrew that." See transcript, p. 16. The Veterans Law Judge then affirmed his understanding that the Veteran had withdrawn the issue of entitlement to service connection for a skin disability. Id. Neither the Veteran nor his representative contested or otherwise objected to that understanding. Furthermore, the Board received a letter from the Veteran's representative, dated June 3, 2013, confirming that the representative "believe[s] the answer is yes" as to the question of whether the Veteran was withdrawing the issue of entitlement to service connection for a skin condition. The Veteran's representative concluded that this was not one of the two issues on appeal. Hence, there remain no allegations of errors of fact or law for appellate consideration as to that issue. As such, the Board does not have jurisdiction to review the appeal of that issue, and it is dismissed. The Veteran has also withdrawn his appeal of the issue of entitlement to service connection for paresthesias. In the June 3, 2013 letter from the Veteran's representative, he correctly stated that the RO has "granted service connection for peripheral neuropathy of all four extremities. Notwithstanding that fact the RO still included the issue [of entitlement to service connection for paresthesias] in a supplemental statement of the case for reasons unknown to us....[W]e believe the issue of service connection for paresthesias was satisfied by the grant of service connection for the peripheral neuropathy." The Veteran's representative concluded that this was not one of the two issues on appeal. Hence, there remain no allegations of errors of fact or law for appellate consideration as to that issue. As such, the Board does not have jurisdiction to review the appeal of that issue, and it is dismissed. Service Connection for Erectile Dysfunction In seeking VA disability compensation, a veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with active service in the Armed Forces, or if preexisting such service, was aggravated therein. Establishing direct service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may also be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran contends in his December 2004 claim that his erectile dysfunction is secondary to medications taken for his service-connected PTSD. At his January 2013 videoconference hearing, the Veteran testified that his erectile dysfunction problems began about six or ten years earlier-i.e., between 2003 and 2007. See transcript, p. 15. He also reported that his erectile dysfunction became an issue after he was diagnosed with diabetes in 2007. Id. The Veteran asserted that his erectile dysfunction is secondary to his service-connected diabetes. Id., p. 16. Consistent with the Veteran's testimony, his service treatment records include no complaints, diagnosis, or treatment of erectile dysfunction. In his August 1970 Report of Medical Examination at separation, a clinician found that his genitourinary (G-U) system was normal. In July 2003, a VA treating physician saw the Veteran at an Agent Orange clinic. The physician opined that the Veteran's "impotence may be related" to his in-service Agent Orange exposure. The Board finds that this opinion is too inconclusive to support a grant of service connection. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Morris v. West, 13 Vet. App. 94, 97 (1999) (a diagnosis that the appellant was "possibly" suffering from schizophrenia was deemed speculative); Bostain v. West, 11 Vet. App. 124, 127-28 (1998), quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993), (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (a generic statement about the possibility of a link is too general and inconclusive); Warren v. Brown, 6 Vet. App. 4, 6 (1993) (a doctor's statement framed in terms such as "could have been" is not probative). In May 2009, VA provided the Veteran with a compensation and pension examination germane to his claim for service connection for erectile dysfunction. The VA examiner noted that the Veteran stated that his erectile dysfunction started about 10 years ago-i.e., in 1999. The Veteran reported that he was diagnosed with Peyronie's disease, that he does not have any erections, and that his penis curls up. After reviewing the claims file, the VA examiner found that the Veteran's erectile dysfunction predates his diabetes-which was service-connected presumptively based on his exposure to Agent Orange-by several years. The examiner further found that the Veteran has a longstanding history of hypertensive vascular disease, which she noted is a very well known risk factor for the development of erectile dysfunction. Based on the foregoing, the VA examiner attributed the Veteran's erectile dysfunction to his high blood pressure and Peyronie's disease. The Board finds that the criteria for service connection for erectile dysfunction have not been met. The VA examiner's May 2009 opinion constitutes competent medical evidence because she is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). Also, the Board finds that the VA examiner's etiological opinion is credible based on its internal consistency and her duty to provide truthful opinions. The Board further finds that the May 2009 VA examiner's opinions are most probative because she considered the Veteran's medical records and discussed his medical history, provided unequivocal and conclusive opinions, and offered clear reasoning demonstrating that the Veteran's history shows that his erectile dysfunction predates his diabetes, and is attributable to his longstanding history of hypertensive vascular disease, which is a very well known risk factor for the development of erectile dysfunction. As the VA examiner's opinion is consistent with the evidence of record-including the dates of onset of the Veteran's hypertension, erectile dysfunction, and diabetes-the Board finds that her reasoning and conclusions warrant the greatest probative weight. Specifically, a Problem List generated by the Chillicothe, Ohio VA Medical Center dated April 2008 shows that the Veteran had been diagnosed with hypertension in March 2002, erectile dysfunction in June 2004, and diabetes mellitus in September 2006. Because the Veteran's documented VA treatment records listing the order of onset of his hypertension, erectile dysfunction, and diabetes, are official medical records used for the purpose of treatment, the Board finds that they are more probative than the Veteran's January 2013 testimony to the effect that his erectile dysfunction became an issue after he was diagnosed with diabetes. See transcript, p. 15. Thus, the May 2009 VA examiner's opinion is based on the correct facts, and warrants the greatest probative weight. The Board recognizes that the Veteran was competent to observe his erectile dysfunction. However, lay evidence is not always competent evidence of a nexus, particularly where complex medical questions or the interpretation of objective medical tests are involved. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (rheumatic fever is not a condition capable of lay diagnosis). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here, the Veteran's December 2004 assertion that his erectile dysfunction is secondary to medications taken for his service-connected PTSD, and his January 2013 videoconference hearing testimony that his erectile dysfunction is secondary to his diabetes, are not competent because the relationship between those disorders is of a complex nature and requires medical expertise and the interpretation of medical literature to evaluate. Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony falls short in proving an issue that requires expert medical knowledge). Consequently, the lay statements from the Veteran asserting a nexus do not constitute competent medical nexus opinions. Moreover, even if the lay nexus opinions were held competent in this case, the Board finds that their probative value is outweighed by the May 2009 VA examiner's opinion based on her greater medical expertise and the consistency of her findings with the chronology of onset on the Veteran's erectile dysfunction after his hypertension but before his diabetes. In sum, the Board finds that the most probative evidence fails to link the Veteran's erectile dysfunction to service, or to his service-connected PTSD or diabetes. Accordingly, reasonable doubt does not apply, and the appeal of the issue is denied. Initial Rating in Excess of 10 Percent for PTSD Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the 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 life. Generally, the degree of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the appellant. 38 C.F.R. § 4.3. The appellant is presumed to be seeking the maximum benefit allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, (1993). The record shows that the Veteran first sought service connection for his PTSD on January 24, 2003. Following a November 2008 Board remand, the RO issued a rating decision in May 2010 that granted the Veteran's claim for service connection and assigned a 10 percent rating. The Veteran filed a timely Notice of Disagreement in May 2011, and the RO issued a Statement of the Case in October 2011. The Veteran filed a timely Substantive Appeal in October 2011. The RO issued supplemental statements of the case in February 2012 and April 2012, continuing the Veteran's 10 percent rating for his PTSD. The Veteran's PTSD has been evaluated under the General Rating Formula for Mental Disorder. 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula, a 10 percent disability rating is warranted when there is 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; symptoms controlled by continuous medication. Id. A 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when there is 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 disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the U.S. Court of Appeals for Veterans Claims (Court) held that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-IV. See 38 C.F.R. § 4,125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is 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 Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). A GAF of 61 to 70 is indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). A GAF score of 41 to 50 indicates 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). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with an appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Following a review of the evidence of record, the Board finds that an initial rating of 30 percent for PTSD is warranted throughout the appellate period. In reaching this decision, the Board has reviewed the evidence of record, to include VA treatment and examination reports, and the Veteran's statements. The Veteran contends in his May 2011 notice of disagreement that a higher initial rating for PTSD is warranted. At his January 2013 videoconference hearing, the Veteran reported taking prescription medications for his PTSD. He also reported experiencing anger, anxiety, and paranoia, and being unable to drive. See transcript, pp. 6-7. The Veteran stated that he does not like crowds and people, avoids military movies, and has consuming and distracting thoughts. Id., pp. 9, 12. The Board has considered the Veteran's extensive records of VA treatment for his service-connected PTSD, as well as the VA examinations dated April 2009 and August 2011. In August 2002, following a positive screen, the Veteran underwent a VA psychiatry consult at which he reported experiencing flashbacks and difficulty sleeping. In December 2002, the Veteran reported experiencing nightmares, flashbacks, and irritability. The VA physician diagnosed him with PTSD, and noted that he is able to work. The VA physician assigned a GAF score range of 60 to 65. In March 2003, the Veteran reported that he continued to have nightmares, flashbacks, and irritability. The VA physician assigned a GAF score range of 55. In June 2003, the Veteran reported experiencing irritability and occasional nightmares and flashbacks. He stated that he was working in construction. The VA physician assigned a GAF score of 60. In July 2004 the Veteran was admitted to a VA medical center following an overdose of alcohol and pills. He stated that when he gets depressed he drinks more often and in greater quantities, which he did not specify. His spouse reported that, following the overdose, the Veteran unsuccessfully attempted to hurt himself with a knife and hang himself with a bed sheet. The Veteran was treated with a stomach pump. Later that month, a VA physician diagnosed the Veteran with continuous alcohol dependency, substance-induced mood disorder, and nicotine dependency. In August 2004, the VA clinician diagnosed the Veteran with a substance-induced mood disorder and alcohol dependence. After considering the Veteran's statements attributing his alcohol consumption to his service-connected PTSD symptoms, as against the VA clinician's diagnoses separating the Veteran's alcohol dependency symptoms from his PTSD symptoms, the Board finds that the VA clinicians' findings are entitled to greater probative weight based on their greater medical knowledge and experience. As such, the Veteran's symptoms and GAF scores listed in entries containing a clinician's diagnosis of substance-induced mood disorder and/or alcohol dependence, but not active PTSD, are not considered part of his PTSD symptomatology. Mittleider v. West, 11 Vet. App. 181 (1998). In September 2007, the Veteran reported taking his psychiatric medication and feeling less depressed and less irritable. He also reported that the medication helps with his nightmares, flashbacks, and sleep disturbance. The VA physician found that the Veteran had a blunt affect. In January 2008, a VA clinician found that the Veteran's affect was pleasant and appropriate; that his thought processes were within normal limits (WNL); and that he had no hallucinations, delusions, or suicidal or homicidal ideations or plans. VA provided the Veteran with a PTSD compensation and pension examination in April 2009. The Veteran reported having nightmares once a month, some startle response with loud noises, and avoidance behavior and anxiety attacks especially when driving. He also endorsed feeling depressed, hopeless and helpless at times. The Veteran stated that he has difficulty sleeping. The VA examining psychiatrist diagnosed the Veteran with PTSD and assigned a GAF score of 65. The examiner found that the Veteran's ability to function is moderately impaired, that he has been able to work all of his life, and that he is able to function in stressful situations. In May 2009, the Veteran saw a VA clinician for a psychiatry consult and endorsed experiencing intrusive memories; recurrent dreams; intense psychological distress in response to internal/external cues; physical symptoms in response to internal or external cues; efforts to avoid thoughts, feelings, or conversations related to the trauma; efforts to avoid activities, places, and people that remind him of the trauma; diminished interest/participation in significant activities; feeling of detachment from others; restricted range of affect; difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and an exaggerated startle response. Later in May 2009, the Veteran received treatment at a VA PTSD clinic. The Veteran reported having nightmares, flashbacks, trouble sleeping, and irritability. The VA physician diagnosed the Veteran with PTSD and assigned a provisional (not full) GAF score of 44. In February 2011, the Veteran reported having some anxiety episodes. The VA physician found that the Veteran was alert, oriented, very cooperative, and smiling. He denied any suicidal or homicidal ideation, and any hallucinations or delusions. The VA physician diagnosed the Veteran with PTSD and assigned a GAF score of 45. In May 2011, the Veteran stated that he thinks about Vietnam every day, has nightmares once or twice a week, and flashbacks once or twice a month. The Veteran reported that he does not like to go to restaurants or be in crowds. The Veteran reported being depressed and anxious, and having a startled reaction. The VA physician diagnosed the Veteran with PTSD and assigned a GAF score of 55. In August 2011, the Veteran reported experiencing "crazy dreams." He reported having anxiety attacks which last for 5 or 10 minutes when driving, and also reported getting nervous when in traffic and when shopping. The VA physician diagnosed the Veteran with PTSD and assigned a GAF score of 55. VA provided the Veteran with a second PTSD compensation and pension examination later in August 2011. The Veteran reported having a depressed mood, anxiety, chronic sleep impairment, and weekly nightmares; he also reported that he had retired in 2005 after a successful 30 year career in construction. The Veteran endorsed experiencing recurrent and distressing recollections and dreams of the stressor event. He also endorsed making efforts to avoid thoughts, feelings or conversations associated with the trauma; making efforts to avoid activities, places or people that arouse recollections of the trauma; and having markedly diminished interest or participation in significant activities. The Veteran endorsed having difficulty falling or staying asleep, hypervigilance, and an exaggerated startle response. The VA examiner found that the Veteran's PTSD symptoms do not cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The VA examiner diagnosed the Veteran with PTSD and assigned a GAF score of 65. The VA examiner found that the Veteran has 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 symptoms controlled by medication. Later in August 2011, the Veteran reported having such symptoms as re-experiencing, arousal, and avoidance; the VA clinician found that there was objective test score evidence of these symptoms. The VA clinician diagnosed the Veteran with PTSD and assigned a GAF score of 58. Based on the evidence of record described above, the Board finds that the Veteran's PTSD results in occupational and social impairment with occasional decrease in efficiency due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks, and chronic sleep impairment. The Board notes that the evidence of record reflects that the Veteran has additional symptomatology which includes flashbacks; difficulty sleeping; nightmares; a blunt affect; some startle response with loud noises; avoidance behavior, including of restaurants and crowds; hopelessness; helplessness; intrusive memories; recurrent dreams; intense psychological distress in response to internal or external cues; physical symptoms in response to internal or external cues; efforts to avoid thoughts, feelings, or conversations related to the trauma; efforts to avoid activities, places, and people that remind him of the trauma; diminished interest or participation in significant activities; feeling detachment from others; difficulty concentrating; hypervigilance; and paranoia. See Mauerhan, 16 Vet. App. 436 (2002). However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 30 percent under the General Rating Formula as they produced no discernible effect on the Veteran's reliability and productivity, or render the Veteran deficient in most areas. They have certainly not produced total occupational and social impairment. While the Veteran does experience some impaired impulse control (such as unprovoked irritability with periods of violence), the Board finds that his overall symptomatology is most consistent with the 30 percent level of severity. Likewise, while the Board acknowledges that the Veteran asserted in treatment in August 2011 that he had stopped working due to physical and mental problems, the Board finds that total occupational impairment is inapplicable both because of the overall symptomatology described above, and because the Veteran told the August 2011 VA examiner that he had retired in 2005 after a successful 30 year career in construction. Therefore, the Board finds that the Veteran's PTSD more nearly approximates a rating of 30 percent. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that his PTSD symptomatology has been essentially stable throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. The Board finds that the Veteran's PTSD symptomatology is fully addressed by the rating criteria under which such disability is rated. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Moreover, even if the rating criteria were found inadequate to describe the severity and symptoms of the Veteran's PTSD, the Board further finds that this case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, the Veteran has not reported frequent periods of hospitalization for his PTSD, and any interference with his pre-retirement employment is contemplated by his 30 percent rating. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, the Court of Appeals for Veterans Claims has held that a total disability rating based on individual unemployability (TDIU) is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). 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, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied, and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Board finds that the most probative evidence-including the Veteran's April 2009 and August 2011 VA examination reports-shows that the Veteran is not unemployable due to his PTSD. Thus, TDIU is not raised by the record. In summary, the Board finds that the Veteran's PTSD symptoms result in occupational and social impairment with occasional decrease in efficiency due to such symptoms as flashbacks; difficulty sleeping; nightmares; irritability; depression; a blunt affect; some startle response with loud noises; avoidance behavior, including of restaurants and crowds; anxiety attacks, especially when driving; hopelessness; helplessness; intrusive memories; recurrent dreams; intense psychological distress in response to internal or external cues; physical symptoms in response to internal or external cues; efforts to avoid thoughts, feelings, or conversations related to the trauma; efforts to avoid activities, places, and people that remind him of the trauma; diminished interest or participation in significant activities; feeling detachment from others; difficulty concentrating; hypervigilance; and paranoia. Accordingly, the Board concludes that a 30 percent rating for PTSD, but no more, is warranted. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1-4.14, 4.130, Diagnostic Code 9411. ORDER The appeal of the issue of entitlement to service connection for a skin rash is dismissed. The appeal of the issue of entitlement to service connection for paresthesias is dismissed. Service connection for erectile dysfunction is denied. A 30 percent disability rating for PTSD is granted, subject to the applicable criteria governing the payment of monetary benefits. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs