Citation Nr: 1325208 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 04-13 802 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to posttraumatic stress disorder (PTSD) and diabetes mellitus, type 2. 2. Entitlement to a rating in excess of 30 percent for PTSD, for the period prior to October 12, 2012, and in excess of 50 percent, for the period on and after October 12, 2012. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: J. Michael Woods, Attorney at Law ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from March 1969 to October 1970. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in Montgomery, Alabama (RO). This case was remanded by the Board in April 2008, September 2010, and September 2012 for additional development. In its September 2012 remand, the Board noted that, in a July 2012 Brief, the Veteran's representative had raised the issue of entitlement to service connection for polysubstance abuse, to include as secondary to PTSD. At that time, the issue had not been adjudicated by the Agency of Original Jurisdiction (AOJ), and the Board therefore found that it did not have jurisdiction over the issue and referred it to the AOJ for appropriate action. The evidence of record does not show that this issue has since been adjudicated by the AOJ. Accordingly, it is once again referred to the AOJ for appropriate action. In addition, in an April 2013 statement, the Veteran raised the issue of whether his benefits were properly calculated and paid, for the period on and after October 12, 2012. This issue also has not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over it, and it is also referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The preponderance of the evidence of record is against a finding that the Veteran's currently diagnosed hypertension is related to service or to a service-connected disability. 2. The medical evidence of record shows that, throughout the entire period on appeal, the Veteran's PTSD was predominantly manifested by nightmares, sleep impairment, intrusive memories, exaggerated startle response, paranoia, hypervigilance, irritability, avoidance behavior, emotional numbness, an abnormal mood, and an abnormal affect. 3. Upon VA examination on March 16, 2009, the examiner specifically found that the Veteran had reduced reliability and productivity due to PTSD symptoms. 4. The Veteran is not precluded from securing or following substantially gainful employment as a result of his service-connected disabilities alone; referral for extraschedular consideration is therefore not warranted. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by active service, nor is it proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for a rating in excess of 30 percent for PTSD, for the period prior to March 16, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a rating of 50 percent, but no higher, for PTSD have been met for the period on and after March 16, 2009. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 4. The criteria for a total disability rating for compensation purposes based on individual unemployability (TDIU) have not been met, and referral for extraschedular consideration is therefore not warranted. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the Veteran, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in November 2003, June 2004, December 2004, March 2006, May 2008, and October 2012. The Veteran has additionally neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representatives suggest actual knowledge of the elements necessary to substantiate the claims. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. In September 2012, the Board remanded the claims on appeal, in part, so that an attempt could be made to obtain records from a private physician. In October 2012, the Veteran was asked to complete an authorization and consent form to allow VA to make an attempt to obtain records from this private physician. The Veteran did not complete this form, and in a November 2012 statement he asked VA to proceed with adjudication of the claim without obtaining medical records from the private physician. VA has also obtained examinations with respect to the claims. As such, the Board is satisfied that there has been substantial compliance with its September 2012 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Hypertension Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic disorders, including hypertension, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by a service connected disability or (b) aggravated by a service connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 488 (1995) (en banc). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). The Veteran's service treatment records are negative for any diagnosis of hypertension. After separation from military service, in a May 2002 VA outpatient medical report, the Veteran reported that he had recently been found to have hypertension, which he thought may have been secondary to back pain. The medical evidence of record shows that hypertension has been consistently diagnosed since approximately May 2002. In an August 2002 VA general medical examination report, the Veteran reported that his blood pressure was found to be elevated during a physical examination in approximately April 2002. He reported that he was subsequently diagnosed with hypertension. After physical examination, the relevant diagnosis was essential hypertension. In a May 2012 VA diabetes mellitus examination report, the examiner was asked whether the Veteran had certain disabilities which were at least as likely as not due to diabetes mellitus. The examiner checked the box next to erectile dysfunction, but left the box next to hypertension blank. An October 2012 VA general medical examination report stated that the Veteran's claims file had been reviewed. The Veteran reported a history of hypertension since 2002, and denied a known history of hypertension or elevated blood pressure during military service. After physical and diagnostic examination, the diagnosis was hypertension. The examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by service. The rationale was that the Veteran was separated from service in 1970, diagnosed with hypertension in 2002, and did not recall any treatment for hypertension in service or within one year of separation from service. The examiner also opined that the Veteran's hypertension was less likely than not related to the Veteran's service-connected PTSD or diabetes mellitus. The rationale was that the Veteran's hypertension was essential, PTSD could cause temporary elevation in blood pressure but did not usually lead to sustained elevation of blood pressure, and the Veteran had stable renal functioning. The Board finds that the preponderance of the evidence of record is against a finding that the Veteran's currently diagnosed hypertension is related to service or to a service-connected disability. The Veteran's service medical records are negative for any diagnosis of hypertension. While the medical evidence of record shows that the Veteran has a current diagnosis of hypertension, there is no evidence of record that hypertension was diagnosed prior to April 2002, over 31 years after separation from service. A prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease incurred in service resulted in any chronic or persistent disability. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); Mense v. Derwinski, 1 Vet. App. 354 (1991). In addition, the preponderance of the medical evidence of record demonstrates that the Veteran's currently diagnosed hypertension is not related to service or to a service-connected disability. The only medical opinions of record which discuss the etiology of the Veteran's hypertension are in the October 2012 VA general medical examination report. That report found that it was less likely than not that the Veteran's hypertension was related to military service, PTSD, or diabetes mellitus. There is no medical evidence of record which refutes or otherwise contradicts these opinions. Under certain circumstance, lay evidence can be competent and sufficient to establish the etiology or diagnosis of a condition. Davidson v. Shinseki, 581 F.3d 1313 (2009). However, such etiological evidence is only competent to the extent that it relies on observable symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board notes that the Veteran's statements alone are sufficient to demonstrate continuity of symptomatology of hypertension. 38 C.F.R. §§ 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, in this case the Veteran does not claim that he experienced high blood pressure continuously since separation from service. In addition, his statements are not competent to demonstrate that his currently diagnosed hypertension is related to service or to his service-connected PTSD or diabetes mellitus. Medical diagnosis and causation involve questions that are beyond the range of common experience and common knowledge and require the special knowledge and experience of a trained physician. As he is not a physician, the Veteran is not competent to make a determination that his hypertension is related to service or to his service-connected PTSD or diabetes mellitus. Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that the preponderance of the competent evidence of record is against a finding that the Veteran's currently diagnosed hypertension is related to service or to a service-connected disability. Furthermore, the evidence of record does not show that any hypertension manifested to a compensable degree within one year following separation from service. Therefore, the Board finds that service connection for hypertension is not warranted. In summary, the Board finds that the preponderance of the competent evidence weighs against the Veteran's claim for service connection for hypertension. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204 (1994); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). Staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Service connection for PTSD was granted by a September 2003 rating decision and a 30 percent rating was assigned under 38 C.F.R. § 4.130, Diagnostic Code 9411, effective May 30, 2002. Subsequently, a February 2013 rating decision assigned a 50 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411, effective October 12, 2012. The medical evidence of record shows that, throughout the entire period on appeal, the Veteran has received VA mental health group therapy on a regular basis. The Board has thoroughly reviewed these records, but will not discuss them individually as these records only include minor commentary on the Veteran's symptomatology and all symptoms that are noted in those records are also reported elsewhere in the relevant medical evidence of record. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). In a June 2003 VA PTSD examination report, the Veteran reported that he had been married twice to the same woman, and had three children. He reported that his symptoms had drastically improved since he began seeking treatment in 2001. The Veteran reported experiencing nightmares approximately once every four months, an exaggerated startle response, paranoia, hypervigilance, insomnia, irritability, and symptoms of hyperalgia. He stated that he had not felt depressed or suicidal since 2001. On objective examination, the Veteran was alert, oriented, engageable, and polite. The Veteran's speech was slightly tremulous but was of normal volume and rate. The Veteran had mild psychomotor agitation, his mood was okay, and his affect was positive for psychomotor agitation. He denied any current suicidal ideation, homicidal ideation, auditory hallucinations, and visual hallucinations. The Veteran's thought process was logical and goal directed, while his insight and judgment were fair. The Axis I diagnosis was PTSD, chronic. The examiner assigned a Global Assessment of Functioning (GAF) score of 65, which contemplates some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but that the Veteran is generally functioning "pretty well" with "some meaningfully interpersonal relationships." See The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Association (1994). In a July 2004 VA PTSD examination report, the Veteran reported experiencing emotional numbness and hypervigilance. On objective examination, the Veteran was casually dressed, cooperative, alert, and oriented to time, person, place, and objects. His mood was anxious, with a congruent affect. His thought process was coherent, and the Veteran's thought content was negative for suicidal and homicidal ideations. He did not have obsessions, compulsions, confabulations, or muteness, and his insight and judgment were adequate. The Axis I diagnosis was PTSD, chronic. The examiner assigned a GAF score of 58, which contemplates moderate symptoms, such as flat affect, circumstantial speech, or occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, such as few friends and conflicts with peers or co-workers. Id. In an August 2004 VA mental health report, the Veteran reported experiencing an improvement in insomnia and nightmares, but reported that he continued to experience intrusive memories. He exhibited avoidance behavior and had transient irritability. The Veteran denied experiencing depression, suicidal ideation, and homicidal ideation, and had no history of any symptoms suggestive of hypomanic or manic episodes. He denied hallucinatory experiences and there was no delusional thinking. The Veteran reported that he was separated and lived alone and denied a history of any effort to take his own life. On mental status examination, the Veteran was casually dressed, adequately groomed, calm, and cooperative. He had good eye contact, normal psychomotor activity, and his speech was spontaneous and normal. His mood was reported as "alright," with an appropriate but constricted affect. The Veteran was negative for suicidal ideation, homicidal ideation, hallucinations, and delusions. His thought content was coherent, logical, and goal directed. The Veteran was alert and oriented, his memory was grossly intact, and his attention, concentration, and recall were adequate. His insight was good while his judgment was intact. The assessment was PTSD, stable. In a November 2004 letter, a VA psychologist stated that the Veteran's PTSD had a severe impact on his daily function and was likely to be chronic in duration. The examiner stated that the Veteran appeared to have been unable to be gainfully employed on a sustained basis since January 2002, primarily due to the effects of PTSD. The letter stated that the Veteran experienced recurrent and intrusive recollections of traumatic experiences, which resulted in a marked restriction of activities of daily living. The Veteran was also reported to experience marked difficulties in maintaining social functioning, and marked difficulties in maintaining concentration, persistence, or pace. The Axis I diagnosis was PTSD, chronic. The examiner assigned a GAF score of 47, which contemplates serious symptoms, such as suicidal ideation, severe obsessional rituals, or frequent shoplifting, or serious impairment in the Veteran's social, occupational, or school functioning, such as "no friends, unable to keep a job." Id. In a March 2005 VA mental health report, the Veteran reported that he was feeling "pretty good" and stated that group therapy had helped him a lot. He reported experiencing an improvement in insomnia and nightmares, but also that he continued to experience intrusive memories and dreams. The Veteran exhibited avoidance behavior and had transient irritability. He denied experiencing depression, suicidal ideation, and homicidal ideation, and had no history of any symptoms suggestive of hypomanic or manic episodes. The Veteran denied hallucinatory experiences and there was no delusional thinking. He reported that he was separated and lived alone. On mental status examination, the Veteran was casually dressed, adequately groomed, calm, and cooperative. He had good eye contact, normal psychomotor activity, and his speech was spontaneous and normal. His mood was reported as "pretty good," with an appropriate but constricted affect. The Veteran was negative for suicidal ideation, homicidal ideation, hallucinations, and delusions. His thought content was coherent, logical, and goal directed. The Veteran was alert, his memory was grossly intact, his insight was good, and his judgment was intact. The assessment was PTSD, stable. The examiner assigned a GAF score of 55, which contemplates moderate symptoms. Id. In a June 2006 VA psychiatry clinic note, the Veteran reported feeling tired, depressed, and angry. He reported that he could not stand crowds and experienced flashbacks and nightmares. The diagnostic impression was PTSD. In a March 2008 VA mental health report, the Veteran complained of sleep disturbances and feeling depressed. He denied experiencing suicidal thoughts, homicidal thoughts, hallucinations, psychotic symptoms, or manic symptoms. The Veteran reported that he was stressed due to financial problems and complained of experiencing anxiety symptoms. The impression was PTSD, chronic. In a second March 2008 VA mental health report dated the same day, the Veteran reported that he was married but had been separated for seven years. He stated that he had been married twice to the same woman, had one biological daughter, and had helped raise two other children. The Veteran reported that he had a good relationship with his wife since their separation. He stated that he was unemployed and had not worked since back surgery in 2002, but stated that he was previously with the same employer for 16 years and was able to work in his position there due to being able to work alone. On mental status examination, his mood was depressed with a flat and congruent affect. He was cooperative, alert, and maintained good eye contact. The Veteran's speech was clear with no suicidal or homicidal thoughts or ideas. His judgment appeared to be good without evidence of psychosis, hallucinations, or delusions. The Veteran reported experiencing sleep impairment, nightmares, night sweats, flashbacks, isolation from others, easy startlement, constant guarding, feeling depressed, road rage, anger outbursts, and conversation avoidance. The Axis I diagnosis was PTSD. In an April 2008 VA mental health report, the Veteran complained of an increase in sleep disturbance, isolative impulses, and anger. The Veteran denied any efforts to take his own life, though he reported having had suicidal thoughts in the past. On mental status examination, the Veteran was clean, neatly groomed, alert, and cooperative. His psychomotor activity was normal, he had good eye contact, and his speech was fluent. The Veteran's mood was "so-so" with a neutral affect. His thought processes were goal directed and he did not have any delusions or hallucinations, though he did re-experience some traumatic events. The Veteran did not have suicidal ideation, homicidal ideation, or homicidal intent. He was fully oriented, his cognitive functions were intact, his insight was good, and his judgment was good. The Axis I diagnosis was PTSD. The VA examiner assigned a GAF score of 53, which contemplates moderate symptoms. Id. In a December 2008 VA mental health report, the Veteran reported a decrease in stress with his family and stated that several had moved out. He reported that he was sleeping better, had an okay appetite, and had fair energy, but his mood was sometimes low. He had no cognitive complaints and did not experience anxiety, psychosis, suicidal ideation, or homicidal ideation. On mental status examination, the Veteran was clean, neat, casually dressed, alert, and cooperative. His psychomotor activity was normal, he had full eye contact, and his affect was pleasant with a mood that was "not that bad." The Veteran's speech was fluent, his thought processes were goal directed, and he did not have any delusions, hallucinations, suicidal ideation, or homicidal ideation. He was fully oriented, his cognitive functions were intact, his insight was good, and his judgment was good. The Axis I diagnosis was PTSD. The examiner assigned a GAF score of 58, which contemplates moderate symptoms. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Association (1994). In a March 16, 2009, VA PTSD examination report, the Veteran reported that he was married but had been separated from his wife for seven years. He stated that he had a friendly relationship with her, but that she was not able to live with him. The Veteran reported that his two daughters called him but his son did not, and that bothered him. He reported that his relationship with his daughters was good. The Veteran reported that he had attended a birthday dinner the previous night for his brother-in-law and that it was difficult for him to be with a crowd in the restaurant. He reported that he had three siblings who he saw occasionally, and had helped his brother with a computer the previous weekend. The Veteran reported that his sisters and their husbands had lived in his house for a month or two recently when they had financial problems, but they had left recently. He reported that he enjoyed seeing his grandsons. The Veteran reported that he stayed in touch with other veterans from his therapy group and that they tried to get together occasionally. He also reported that he typically went to monthly meetings of the Vietnam Veterans of America, though he had not been to a meeting in about six months and stated that his activities had been limited by car problems. The Veteran reported enjoying jazz, fishing, riding his bicycle, watching movies, photography, and using the computer. He reported that he talked with women on online dating sites, but had not been out with any of them. He denied a history of attempts to harm himself, though he reported a history of violence in that he had broken a phone, thrown his bayonet at the wall, and hit the walls with his fists when he was upset. The examiner stated that the Veteran was moderately impaired in his psychosocial functioning. On psychiatric examination, the Veteran was neatly groomed, appropriately dressed, and casually dressed. His psychomotor activity was unremarkable, while his speech was unremarkable, spontaneous, and clear. The Veteran's attitude was cooperative, friendly, relaxed, and attentive. His affect was appropriate, while his mood was objectively neutral, and subjectively distant and "spacey." The Veteran's attention was impaired, but he was oriented to person, time, and place. His thought process and content were unremarkable, though he had difficulty trusting people. The Veteran did not have delusions or hallucinations, and no abnormalities of judgment or insight were noted. He did experience sleep impairment, but did not have inappropriate behavior, obsessive or ritualistic behavior, or panic attacks. The Veteran interpreted proverbs appropriately and denied homicidal thought, though he reported suicidal ideation without plan or intent. He had fair impulse control and no episodes of violence, but reported that he had destroyed objects when he was angry and sometimes had to leave a situation when he became very angry for fear of hurting someone. He was able to maintain minimum personal hygiene and did not have a problem with activities of daily living. The Veteran's remote and immediate memory were considered normal, but his recent memory was mildly impaired. The examiner stated that the Veteran's re-experiencing symptoms were mild to moderate in intensity while his avoidant and hyperarousal symptoms were moderate in intensity. The Axis I diagnosis was PTSD, chronic. The examiner assigned a GAF score of 58, which contemplates moderate symptoms. Id. The examiner stated that the Veteran did not have total occupational and social impairment due to PTSD. He also did not have deficiencies in judgment, thinking, family relations, work, and mood. However, the Veteran did have reduced reliability and productivity due to PTSD symptoms. In an April 2009 VA mental health report, the Veteran reported that he was able to get all of the young people in his family to move out except a nephew. The Veteran reported that he tried to avoid reminders of war and stayed on guard. He reported that he was sleeping the same, had an okay appetite and energy, and his mood was fair. He reported that he was occasionally forgetful and experienced anxiety around crowds or any reminders of war, but did not experience, psychosis, suicidal ideation, or homicidal ideation. On mental status examination, the Veteran was clean, neat, alert, and cooperative. His psychomotor activity was normal, he had good eye contact, his affect was appropriate with a mood of wanting to maintain his current mental status. The Veteran's speech was fluent, his thought processes were organized, and he did not have any delusions, hallucinations, suicidal ideation, or homicidal ideation. His orientation was okay, his cognitive functions had no impairment, his insight was good, and his judgment was generally fair. The Axis I diagnosis was PTSD. The examiner assigned a GAF score of 58, which contemplates moderate symptoms. Id. In an April 2011 VA PTSD examination report, the Veteran reported experiencing a moderately depressed mood and anxiety. He reported that he had been separated from his wife for the previous nine years and lived alone, but maintained contact with his children and recently went to their house to take pictures of his granddaughter who was going to Prom. The Veteran reported that he had seen his family more over the previous year than he had in a long time, and he stated that he maintained occasional contact with his two surviving siblings. He reported that he enjoyed spending time with veterans in his therapy group, and went to Washington, DC with them the previous August. He denied a history of attempts to harm himself, but reported a history of violence in that he had an altercation with a family member who provoked him. The examiner stated that the Veteran was moderately impaired with regard to psychosocial functioning. On psychiatric examination, the Veteran was appropriately and casually dressed. His psychomotor activity was unremarkable, while his speech was unremarkable, clear, and coherent. The Veteran's attitude was cooperative, friendly, and attentive. His affect was appropriate, while his mood was "a little down." The Veteran's attention was intact and he was oriented to person, time, and place. His thought process and content were unremarkable. The Veteran did not have delusions or hallucinations, and no abnormalities of judgment or insight were noted. He did experience sleep impairment, but did not have inappropriate behavior or obsessive or ritualistic behavior. He experienced moderate brief panic attacks on an irregular basis. The Veteran interpreted proverbs appropriately and denied homicidal and suicidal thoughts. He had fair impulse control and no episodes of violence, but reported that he experienced irritability, isolated himself when he felt angry, and engaged in a physical altercation with a family member who provoked him at a birthday celebration in January. He was able to maintain minimum personal hygiene and did not have a problem with activities of daily living. The Veteran's remote, recent, and immediate memory were normal. The examiner stated that the Veteran's symptoms were chronic and moderate. The Axis I diagnosis was PTSD, chronic. The examiner assigned a GAF score of 58, which contemplates moderate symptoms. Id. The examiner stated that the Veteran did not have total occupational and social impairment due to PTSD. He also did not have deficiencies in judgment, thinking, family relations, work, and mood, nor did he have reduced reliability and productivity due to PTSD symptoms. However, he did have an occasional decrease in work efficiency with intermittent period of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning. In a November 2011 VA mental health note, the Veteran reported that he had taken in his niece and nephew, which had added stress. He reported experiencing irritability, difficulty concentrating, and preoccupation with traumatic memories. He reported that his sleep was not so good, his appetite was so-so, his energy was somewhat less, and his mood was a bit low. He reported that he was forgetful, his anxiety was somewhat worse with some shaking, and he had chronic suicidal ideation, but without intent or plan. He did not experience, psychosis or homicidal ideation. On mental status examination, the Veteran was casually dressed, clean, alert, and cooperative. His psychomotor activity was a bit slow, he had okay eye contact, his affect was somewhat depressed, and his mood was "not too good." The Veteran's speech was clear, his thought processes were goal-directed, and he did not have any delusions, hallucinations, suicidal ideation, or homicidal ideation. His orientation was okay, his cognitive functions were grossly intact, and his insight and judgment were okay. The Axis I diagnosis was PTSD. The examiner assigned a GAF score of 52, which contemplates moderate symptoms. Id. An October 2012 VA PTSD examination report gave an Axis I diagnosis of PTSD, chronic with depressive features, and assigned a GAF score of 54, which contemplates moderate symptoms. Id. The examiner opined that the Veteran's level of occupational and social impairment was best summarized as occupational and social impairment with reduced reliability and productivity. The Veteran reported that he lived alone, did not trust other people, and did not let other people get close to him. He reported that he had lost all interest in dating, though he talked to women from time to time. The Veteran reported that he occasionally talked to his sister and his children, but did not have a car so his transportation was limited. He reported that a veteran friend brought him to the present appointment and that he had a cousin who he saw occasionally. The Veteran reported that he mainly associated with family members and members of his PTSD group. He reported that he enjoyed television and fishing, and his most recent fishing trip was the previous week. The Veteran was found to have a depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, a flattened affect, and disturbances of motivation or mood. He did not have any other symptoms listed under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. The Veteran also reported that his mood was variable, he sometimes felt inclined to stay home all day, his appetite was poor, his temper was quicker, and he avoided crowds. He reported that he had intermittent suicidal ideation, the most recent occurrence being a few days before, but he denied having any clear intent or plan. The Rating Schedule provides that a 30 percent rating is warranted for psychiatric disorders with 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, weekly or less often panic attacks, chronic sleep impairment, mild memory loss, such as forgetting names, directions, recent events. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted for psychiatric disorders with 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 such as, 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 rating is warranted for psychiatric disorders with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for psychiatric disorders with 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 of the Veteran 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. Prior to March 16, 2009 The Board finds that the medical evidence of record shows that, throughout the entire period on appeal, the Veteran's PTSD was predominantly manifested by nightmares, sleep impairment, intrusive memories, exaggerated startle response, paranoia, hypervigilance, irritability, avoidance behavior, emotional numbness, an abnormal mood, and an abnormal affect. The medical evidence of record shows that, at various points during the period prior to March 16, 2009, the Veteran has reported experiencing symptoms which are suggestive of some of those which are contemplated by a 50 percent rating. However, the Board finds that the preponderance of the evidence of record shows that the Veteran's PTSD symptoms were most analogous with, and more nearly approximated by, a 30 percent rating prior to March 16, 2009. For the period prior to March 16, 2009, the Veteran was not found to have circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; or impaired abstract thinking. While the Veteran experienced an abnormal affect and was found to have a depressed mood, the Veteran's affect was only occasionally abnormal and his depressed mood is specifically contemplated by the Veteran's 30 percent rating. The medical evidence of record also shows that the Veteran did experience difficulty in establishing and maintaining effective work and social relationships for the period prior to March 16, 2009, but this was the only symptom specifically contemplated by a 50 percent rating that the Veteran experienced consistently throughout the period prior to March 16, 2009. In addition, the evidence of record does not show that this difficulty, or indeed any of the Veteran's symptoms, resulted in occupational and social impairment with reduced reliability and productivity prior to March 16, 2009. With respect to occupational impairment, prior to retiring in 2002 following back surgery, the Veteran was gainfully employed for 16 years with a steel company. The Veteran has repeatedly stated that he was able to maintain this employment because he had worked alone, nevertheless, the Veteran was still able to maintain employment for 16 years and he retired due to a back injury that was unrelated to his PTSD. In addition, he subsequently attempted to start his own business, but was unable to do so for reasons not attributed to PTSD. Regarding social impairment, the Board recognizes that the Veteran has been separated from his wife throughout the entire period on appeal. However, the Veteran has repeatedly stated that he has maintained a good relationship with his wife. In addition, he has repeatedly stated that, throughout the entire period on appeal, he has consistently interacted with family members and veteran friends on regular occasions. The Veteran repeatedly describes his relationships with these people in positive terms, particularly with his wife, children, and friends, despite some difficulties with more distant family members. He also has reported that he routinely leaves the house for social or recreational activities on at least a moderately regular basis. In summary, the evidence of record demonstrates that any social and occupation impairment caused by the Veteran's PTSD symptomatology was not sufficiently severe to result in reduced reliability and productivity prior to March 16, 2009. As such, a rating in excess of 30 percent is not for assignment prior to March 16, 2009, as the evidence of record does not show that the Veteran's PTSD symptoms caused occupational and social impairment with reduced reliability and productivity. The evidence of record is also against a finding that the Veteran's symptoms resulted in deficiencies in most areas such as work, school, family relations, judgment, thinking or mood, and the criteria for a 100 percent rating require total social and occupational impairment as a result of the Veteran's PTSD, and with the Veteran's existing and ongoing relationships, total social impairment is clearly not shown. The criteria for a 100 percent rating additionally include symptoms of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to be able to perform the activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss of the names of close relatives, the Veteran's own occupation, or own name, and none of these symptoms has been shown. On and After March 16, 2009 Upon VA examination on March 16, 2009, the examiner specifically found that the Veteran had reduced reliability and productivity due to PTSD symptoms. Such a finding was a specific recitation of the dominant criteria for a rating of 50 percent for PTSD. Id. The Board notes that the actual symptomatology that the Veteran experienced has remained largely of the same types throughout the entire period on appeal. However, such a statement indicates that the March 2009 examiner felt that severity of the Veteran's PTSD symptoms was most closely analogous with that contemplated by a 50 percent rating as of March 16, 2009. Accordingly, a 50 percent rating is warranted for the Veteran's PTSD symptoms, for the period on and after March 16, 2009. The medical evidence of record shows that, at various points during the period on and after March 16, 2009, the Veteran has reported experiencing symptoms which are suggestive of some of those which are contemplated by a 70 percent rating. However, the preponderance of the evidence of record shows that the Veteran's PTSD symptoms since March 16, 2009, are most analogous with and more nearly approximated a 50 percent, but not higher, rating. For the period on and after March 16, 2009, while the Veteran was noted to have anxiety and depression, it was never reported to be near-continuous and to affect his ability to function independently, appropriately, and effectively. In addition, there is no evidence that the Veteran's PTSD was ever manifested by speech which was intermittently illogical, obscure, or irrelevant; spatial disorientation; or neglect of personal appearance and hygiene. While the Veteran reported in October 2012 that he did not care about hygiene and appearance some days, the Veteran's appearance was never found to be deficient on objective examination. The Veteran also reported a history of irritability and violence, but these reports were confined to a few instances and were not regular occurrences. As such, the Board finds that the Veteran's irritability and violent episodes were not sufficiently frequent or severe to warrant a 70 percent rating for his PTSD any point during the period on appeal. Similarly, while the Veteran reported suicidal ideation at various points throughout the entire period on appeal, he always denied any intent or plan and there Veteran was never found to be in a persistent danger of hurting himself or others. Furthermore, while the Veteran reported experiencing stress at various points, it was narrowly focused on specific areas of life, such as financial status, and was not demonstrated to be analogous to a general difficulty in adapting to stressful circumstances in multiple areas. The Veteran was also able to resolve stressful circumstances, such as asking family members to move out of his home. Accordingly, the Board finds that the preponderance of the evidence of record shows that the Veteran's stress symptoms were not analogous to difficulty in adapting to stressful circumstances. 38 C.F.R. § 4.130, Diagnostic Code 9411. The evidence also shows that the Veteran has never had a total inability to establish and maintain effective relationships. The evidence of record clearly demonstrates that he has social impairment. However, the Veteran has also consistently reported that he maintains relationships with family members and friends from his PTSD group, and sees them on a somewhat regular basis, including fishing trips and trips out-of-state. That evidence is indicative of at least some ability to establish and maintain effective relationships. Therefore, the Board finds the Veteran's symptoms more nearly approximate difficulty in establishing and maintaining effective relationships, as is contemplated by the criteria for a 50 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board finds that the preponderance of the medical evidence of record shows that the Veteran's PTSD was of an overall severity which is not sufficient to warrant a rating in excess of 50 percent at any point during the period on and after March 16, 2009. Most significantly, the April 2011 VA PTSD examination report specifically stated that the Veteran's PTSD caused an occasional decrease in work efficiency with intermittent period of inability to perform occupational tasks, but with generally satisfactory functioning, while the October 2012 VA PTSD examination report specifically opined that the Veteran's level of occupational and social impairment was best summarized as occupational and social impairment with reduced reliability and productivity. These assessments are direct quotations of the dominant criteria for the 30 percent and 50 percent ratings under the Schedule, respectively, and those findings clearly demonstrate that the examiners felt the Veteran's symptoms were not analogous to those contemplated by a 70 percent rating in either April 2011 or October 2012. The Board notes that the November 2004 letter from a VA psychologist stated that the Veteran's PTSD had a severe impact on his daily function, and a marked restriction of activities of daily living, marked difficulties in maintaining social functioning, and marked difficulties in maintaining concentration, persistence, or pace. However, the severity of the symptoms described in this letter are not consistent with the symptoms described throughout the entire period on appeal, including during the period prior to March 16, 2009. Specifically, no other medical report has found that the Veteran's PTSD caused any restrictions of activities of daily living, let alone marked restrictions. Similarly, the Veteran's concentration was repeatedly found to be normal on examination. While decreased concentration was noted on examination in March 2009, the examiner specifically characterized it as being mild in severity. Furthermore, the examiner's assigned GAF score of 47 is entirely inconsistent with all other GAF scores reported throughout the entire period on appeal. The November 2004 examiner assigned a GAF score of 47, which contemplates serious symptoms. However, ten other GAF scores during the period on appeal have contemplated either mild or moderate symptoms, including GAF scores dated in July 2004 and March 2005, only a few months before and after the November 2004 letter. As such, the Board finds that the November 2004 letter from a VA psychologist reported findings which are not consistent with the other evidence of record and constitute, at most, a temporary exacerbation of symptomatology that was not representative of the overall severity of the Veteran's PTSD. The Board would also like to again point out that with the Veteran's existing and ongoing relationships, total social impairment is clearly not shown. The criteria for a 100 percent rating additionally include symptoms of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to be able to perform the activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss of the names of close relatives, the Veteran's own occupation, or own name, and with the exception of the onset of some cognitive impairment, none of the symptoms has been demonstrated. This claim has also been reviewed with consideration of whether further staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's PTSD symptoms beyond those discussed above, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that a rating in excess of those assigned herein would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Hart, 21 Vet. App. 505. Generally, rating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular ratings for that disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun, 22 Vet. App. 111. If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular rating is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities ratings for PTSD inadequate. The Veteran's PTSD was rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's PTSD was predominantly manifested by symptoms of nightmares, sleep impairment, intrusive memories, exaggerated startle response, paranoia, hypervigilance, irritability, avoidance behavior, emotional numbness, an abnormal mood, and an abnormal affect. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability ratings assigned herein for his PTSD. Ratings in excess of the ratings assigned herein are provided for certain manifestations of PTSD, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the ratings assigned herein for the Veteran's PTSD reasonably describe the Veteran's disability level and symptomatology and, therefore, the schedular ratings assigned herein are adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization for PTSD. To the extent that the Veteran claims to experience interference with employment related to PTSD, certain degrees of occupational impairment are already contemplated by the ratings assigned herein. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.130, Diagnostic Code 9411. In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's PTSD does not meet the criteria for a rating in excess of 30 percent prior to March 16, 2009, or in excess of 50 percent on and after March 16, 2009. Therefore, the claim for increased ratings beyond those assigned herein is denied. Gilbert, 1 Vet. App. 49; Massey, 7 Vet. App. 204. TDIU Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability: that is, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. In such an instance, if there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Individual unemployability must be determined without regard to any nonservice-connected disabilities or the Veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). If a Veteran does not meet the applicable percentage standards set forth in 38 C.F.R. § 4.16(a), the issue of entitlement to a total rating due to unemployability may be submitted to the Director, Compensation and Pension Service, for extraschedular consideration where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b); Fanning v. Brown, 4 Vet. App. 225 (1993). Service connection is currently in effect for PTSD, rated 50 percent disabling, and diabetes mellitus, type 2, rated 20 percent disabling. The combined disability rating is 60 percent. 38 C.F.R. § 4.25 (2012). Therefore, the percentage criteria of 38 C.F.R. § 4.16(a) are not met. The evidence of record shows that the Veteran has been unemployed since 2002, and he has consistently reported that his service-connected PTSD impacts his ability to work. However, the Board finds that the preponderance of the evidence of record does not reflect that the Veteran is precluded from securing or following substantially gainful employment as a result of his service-connected disabilities alone. In an August 2002 private psychological evaluation, the Veteran reported that he had worked for 15 years as a torch operator at a steel company, and stopped because he "couldn't do the work, took an early retirement." He reported that he subsequently started a used car business, but closed it in May 2002. When asked what would prevent him from working presently, the Veteran cited his back, knees, shaking hands, and muscle spasms. After examination, the examiner noted that the Veteran indicated that his primary occupational impediments were related to his physical problems. The examiner opined that, based on the psychological evidence, the Veteran should be able to understand and remember simple commands, as well as respond appropriately to supervisors and coworkers in occupational settings. An August 2002 private physical examination report stated that the Veteran had significant workplace limitations due to his low back and bilateral knee pain. A November 2002 letter from a private physician stated that the Veteran had undergone spinal surgery in October 2002, resulting in severe limitations which would last 12 to 18 months. The examiner felt that the Veteran was disabled from any gainful employment. A June 2003 Social Security Administration decision found that the Veteran had been disabled for SSA purposes since January 10, 2001, due to a bilateral knee disability, a spinal disability, and PTSD. A November 2004 letter from a VA psychologist stated that the Veteran appeared to have been unable to be gainfully employed on a sustained basis since January 2002, primarily due to the effects of PTSD. A March 2009 VA PTSD examination report specifically found that the Veteran's PTSD symptoms did not result in total occupational and social impairment. The examiner noted that the Veteran reported that he had always worked in a setting where he could work alone. The examiner opined that it was probable that the Veteran would continue to function most effectively in such a setting, though it was noted that the Veteran was able to interact appropriately with other people when necessary. His memory and concentration made work that required close, sustained attention and concentration inadvisable. However, he was capable of following directions and understanding instructions, and his PTSD symptoms did not restrict him physically. An April 2009 VA general medical examination report stated that the Veteran's service-connected diabetes mellitus did not prevent any form of gainful employment. Of the Veteran's nonservice-connected disabilities, his hypertension and sleep apnea were found to not prevent any form of gainful employment, while his spine disability and bilateral knee disability prevented employment of a physical nature, though not of a sedentary nature. An April 2011 VA PTSD examination report opined that the Veteran's PTSD symptoms moderately impaired his occupational functioning, but he was not considered unemployable due to PTSD symptoms alone. The report specifically found that the Veteran's PTSD symptoms did not result in total occupational and social impairment. A May 2012 VA diabetes mellitus examination report opined that the Veteran's diabetes mellitus, and its associated complications, did not impact his ability to work. An October 2012 VA general medical examination report stated that the Veteran's back and knee disabilities prevented heavy physical labor but did not preclude sedentary work. The Veteran reported that he was not working due to his back disability, knee disability, and diabetes mellitus. An October 2012 VA diabetes mellitus examination report opined that the Veteran's diabetes mellitus, and its associated complications, did not impact his ability to work. An October 2012 VA PTSD examination report found that the Veteran's PTSD symptoms did not result in total occupational and social impairment. The Board finds that the preponderance of the evidence of record is against a finding that the Veteran is precluded from securing or following substantially gainful employment as a result of his service-connected disabilities alone. The preponderance of the evidence of record demonstrates that the Veteran is likely unemployable, however this unemployability is not due to the Veteran's service-connected disabilities alone. The only medical evidence of record which states that the Veteran's service-connected disabilities alone render him unemployable is the November 2004 letter from a VA psychologist, which opined that the Veteran was unemployed primarily due to the effects of PTSD. However, as noted above, this letter reported findings which were not consistent with the other evidence of record and constituted, at most, a temporary exacerbation of symptomatology that was not representative of the overall severity of the Veteran's PTSD. Accordingly, the Board finds that the November 2004 letter warrants low probative weight. All other medical reports of record which address whether the Veteran's service-connected disabilities alone render him unemployable found that they did not. These medical reports include the March 2009 VA PTSD examination report, April 2009 VA general medical examination report, April 2011 VA PTSD examination report, May 2012 VA diabetes mellitus examination report, October 2012 VA diabetes mellitus examination report, and October 2012 VA PTSD examination report. Other medical reports of record, such as the August 2002 private physical examination report and the November 2002 letter from a private physician, indicated that the Veteran was unemployed or unemployable due to nonservice-connected disabilities. There is also evidence of record, such as the June 2003 Social Security Administration decision and the October 2012 VA general medical examination report, which stated that the Veteran was unemployed or unemployable due to a combination of his spine disability, knee disabilities, PTSD, and diabetes mellitus. To the extent that the Veteran is unemployable due to this combination of disabilities, TDIU is not warranted for an inability to work due to a combination of service-connected and nonservice-connected disabilities. 38 C.F.R. §§ 3.341(a), 4.19 (2012); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Accordingly, the Board finds that the evidence of record does not show that the Veteran is precluded from securing or following substantially gainful employment as a result of his service-connected disabilities alone, without regard to any nonservice-connected disabilities, in order to warrant referral for extraschedular consideration under 38 C.F.R. § 4.16(b). Accordingly, the Board finds that the preponderance of the evidence is against entitlement to TDIU. The Veteran does not meet the percentage criteria under 38 C.F.R. § 4.16(a) and the evidence does not otherwise demonstrate an inability to secure or follow a substantially gainful occupation due to his service-connected disabilities alone that would warrant referral for extraschedular consideration. The Board finds that the preponderance of the evidence is against the Veteran's claim. Therefore, the claim is denied. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. 49 (1990). ORDER Service connection for hypertension is denied. A rating in excess of 30 percent for PTSD, for the period prior to March 16, 2009, is denied. A rating of 50 percent, but not higher, for PTSD is granted, for the period on and after March 16, 2009. A total disability rating for compensation purposes based on individual unemployability is denied. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs