Citation Nr: 1335683 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 08-15 946 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in White River Junction, Vermont THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disability, to include schizophrenia and mood disorder, not otherwise specified (NOS). 2. Entitlement to total rating for compensation purposes based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Vermont Veterans Affairs Section, Military Department WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD W.T. Snyder, Counel INTRODUCTION The Veteran served on active duty for training from January to May 1997 as a member of the Vermont Army National Guard (VTARNG), and on active duty from July 1997 to May 1998. Following the active duty tours, he remained a member of the VTARNG. This appeal to the Board of Veterans' Appeals (Board) arose from a September 2007 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Togus, Maine, that in pertinent part denied the benefits sought on appeal. Jurisdiction over the Veteran's claims has remained with the RO in White River Junction, Vermont. The Veteran testified before the undersigned at a July 2008 videoconference hearing at the RO. A transcript of the hearing has been associated with his claims folder and reviewed. In February 2009, August 2010, February 2012, and February 2013, the Board remanded the case to the Appeals Management Center (AMC) in Washington, DC, for further development. The Veteran has a Virtual claims file, which is a highly secured paperless repository, associated with his appeal. The Board has considered the documents in both files while reviewing this appeal. FINDINGS OF FACT 1. The Veteran did not receive an examination at the time of his acceptance and enrollment for either period of active duty. 2. The Veteran's acquired psychiatric disability, to include schizophrenia and mood disorder NOS, clearly and unmistakably pre-existed service and clearly and unmistakably was not aggravated in active service beyond natural progression. 3. The Veteran's service-connected disabilities do not preclude him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The Veteran's acquired psychiatric disability, to include schizophrenia and mood disorder NOS, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1153 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307(a), (d) (2013). 2. The criteria for a TDIU or for further referral for consideration of TDIU on an extraschedular basis have not been met. 38 U.S.C.A. § 1155 (West 2002), 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) VCAA Duty to Notify The VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b)(1). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the Veteran was sent a letter in February 2007 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. The United States Court of Appeals for Veterans Claims (Court) has interpreted the provisions of 38 C.F.R. § 3.103(c)(2) as imposing two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues; and, the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the July 2008 hearing, the undersigned identified the issues before the Board, and asked questions of the Veteran that ensured his testimony addressed the relevant rating criteria. Further, the undersigned held the record open for submission of additional evidence. Hence, the Board finds the Bryant notice requirements were complied with. Accordingly, no further development is required with respect to the duty to notify. VCAA-Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). VA has obtained records of treatment reported by the Veteran, including service treatment records, records from the Social Security Administration, private medical records and arranged VA examinations of the Veteran. The Board remanded the case in August 2010 so service treatment records recently obtained could be reviewed and considered by the AMC. The Veteran was afforded a VA examination in July 2005. Although there was evidence to support the examiner's negative nexus opinion, the Board, in the February 2012 remand, found the examination inadequate because it did not address whether the disability clearly and unmistakably pre-existed service. In other words, the Board remanded so the correct legal standard could be applied. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination. 38 U.S.C. § 5103A; 38 C.F.R. § 3.309(c)(4); see also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). An examination is adequate "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.' " Stefl, 21 Vet. App. at 123 (quoting Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994)). It is a medical examiner's responsibility to provide a well-supported opinion so that the Board may carry out its duty to weigh the evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (concluding that medical opinion is not entitled to any weight "if it contains only data and conclusions"); Stefl, 21 Vet. App. at 124 (stating VA medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Court Of Appeals For Veterans Claims (Court) has also held that an examination is inadequate if the examiner ignores a veteran's assertions of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (finding error where "the VA examiner did not indicate whether he considered Mr. Barr's assertions of continuity of symptomatology"). The July 2013 examination report reflects the examiner again reviewed the claims file and provided an adequate explanation for the opinion she had rendered in April 2012. The examiner also gave full consideration to the Veteran's reported history. As noted later in this decision, the examiner's opinion is not contradicted by the evidence of record. Hence, the examination is adequate for appellate review. Nieves-Rodriguez, 22 Vet. App. 295, 304; Stefl, 21 Vet. App. at 124. The Board also remanded the case in February 2013 so additional treatment records identified by the Veteran could be obtained. The Board notes two of the private treatment entities contacted for records related to the Veteran informed the AMC they required more specific information on the authorization to release records. After a May 2013 AMC letter advised the Veteran of this fact, the Veteran informed the RO in June 2013 via telephone that all of the records he deemed pertinent to his claim were in the claims file. Hence, the AMC took no further efforts to obtain the records. Neither the Veteran nor his representative asserts that there are additional records to be obtained. In light of all of the above, VA has complied with its duty to assist the Veteran with his claims. See 38 C.F.R. § 3.159(c). Hence, the Board may address the merits of the appeal without prejudice to the Veteran. Applicable Law and Regulation Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology, if a chronic disease listed in 38 U.S.C.A. § 1101, 38 C.F.R. § 3.309(a), is demonstrated in active service or an applicable presumptive period. Walker v. Shinseki, 708 F.3d 1131 (Fed. Cir. 2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (lay person competent to testify to pain and visible flatness of his feet); Layno v. Brown, 6 Vet. App. 465, 469 (1994). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. 488, 496 (2997) (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). 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). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as psychoses, are presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). This presumption, however, is rebuttable. 38 C.F.R. § 3.307(d). A Veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C.A. § 1111. The presumption of soundness attaches only where there has been an induction examination during which the disability about which the Veteran later complains was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulations provide expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id. at (b)(1). For purposes of illustrating the analysis to be used in such cases, the Board notes the decision of the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) in Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004), that summarized the effect of 38 U.S.C.A. § 1111on claims for service-connected disability: When no preexisting condition is noted upon entry into service, the Veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the "preexisting condition. 38 U.S.C.A. § 1153. If this burden is met, then the Veteran is not entitled to service-connected benefits. If the government fails to rebut the presumption of soundness under section 1111, however, the Veteran's claim is one for service connection. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. See 38 C.F.R. § 3.322. On the other hand, if a preexisting disorder is noted upon entry into service, the Veteran cannot bring a claim for service connection for that disorder, but the Veteran may bring a claim for service-connected aggravation of that disorder. In that case section 1153 applies and the burden falls on the Veteran to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under section 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306; Wagner, 370 F. 3d at 1096; Jensen, 19 F.3d at 1417. Evidence In October 1985, a psychologist noted that the testing suggested the Veteran was subject to mood swings in which his mood would shift from expansive and outgoing to depression spontaneously. He was currently experiencing mild anxiety. The provisional diagnosis on admission noted a 1985 head injury in Axis III. On discharge, the Axis I diagnoses included rule-out schizopreniform disorder and schizophrenia. A Private November 1985 report notes the Veteran had a five-year history of extensive alcohol and illicit drug use. He reported his mind started to "feel like it was emptying out" in September 1985. Based on the results of psychological testing, a clinical psychologist noted the Veteran's reported history of alcohol abuse, and the probability of past blackouts, suggested the possibility the Veteran had experienced auditory hallucinations should be investigated. These records were received by the service department after the Veteran was on active duty. The Veteran underwent private psychiatric hospitalization in December 1985 and January 1986. A discharge summary, which the service department may or may not have had access to, notes the Veteran's admission in late 1985 and reports no psychiatric history prior to October 1985, when he was admitted to another facility for alcohol treatment. The report notes that prior to the current admission, the Veteran had manifested neurovegetative symptoms, and he became agitated and paranoid with auditory hallucinations, and he threatened to kill a friend. An EEG conducted during the November 1985 hospitalization revealed temporal slowing. The report notes an April 1985 MVA in which the Veteran was unconscious for five minutes without evidence of fracture or concussion. In a report of medical history completed for enlistment in the ARNG in December 1996, the Veteran noted no relevant history. He indicated that he had never had depression, or had nervous trouble of any sort. The December 1996 report of medical examination for enlistment in the ARNG reflects the Veteran was assessed as psychiatrically normal. The Veteran was not afforded examinations when he was activated for either period of active duty. Service treatment records for the January to May1997 period of active duty are silent for any complaints or treatment related to an acquired mental disorder. There is no indication an examination was conducted in May 1997 at the end of the Veteran's tour. Neither is there a report of examination related to the Veteran's activation for his tour of active service from July 1997 to May 1998. Service treatment records indicate that, in November 1997, the Veteran was hospitalized at Walter Reed following the onset of psychiatric symptoms (e.g., impaired speech, thought processes, insight and judgment and unruly behavior) while stationed in Korea. He underwent extensive psychiatric evaluation and treatment and was diagnosed as having a psychotic disorder due to a traumatic brain injury (TBI) incurred prior to service. He was found medically unacceptable for service and discharged. The Medical Evaluation Board (MEB) that reviewed the Veteran's case had access to pre-service reports of psychiatric evaluation in addition to the extensive history obtained from the Veteran. The MEB report notes the Veteran reported having started significant consumption of alcohol at age 16 that progressed to up to 12 beers three times a week by time he was in college. His illicit drug use included cocaine experimentation and marihuana prior to entering active service. The Veteran reported two serious alcohol-related injuries. The first was at age 18 when he sustained a skull fracture while fighting. He was intoxicated at the time. The second, also while under the influence of alcohol, was a motor vehicle accident (MVA) where the Veteran experienced a head injury with brief loss of consciousness. He reported the onset of intermittent auditory hallucinations after the first head injury. Psychological testing conducted at Walter Reed was interpreted as revealing odd and circumstantial thinking, with irrational and bizarre associations of persecutory thought processes. The Veteran's disordered thinking was perseverative and somewhat disabling. The psychologist opined the Veteran had a significant thought disorder. The report reflects a neurologist noted the Veteran had a normal neurological examination and concurred with the mental status examination. The neurologist opined the Veteran's ongoing psychotic features were strongly representative of a psychosis induced by multiple TBIs, as represented by ongoing disorganized speech and occasional derailment, grossly disorganized behavior interpersonally and flattened effect. The MEB report notes Axis I diagnoses as follows: psychotic disorder due to TBI, with delusions, manifested by delusions of having been in the Special Forces and trained at Officer Candidate School; intermittent auditory hallucinations, tangentiality, and grossly disorganized behavior (i.e., walking in circles, belligerent behavior), with inappropriate affect, etc.; and, alcohol dependence in early full remission without physiological dependence. An April 1998 private report notes the Veteran's past diagnoses with schizophreniform disorder and psychotic disorder due to TBI stemming from a MVA in 1985. The report notes the Veteran reported a 1982 skull fracture and a 1985 MVA in which he sustained a head injury. The Veteran reported he lost consciousness in both accidents. The report reflects an Axis I diagnosis of psychotic disorder secondary to a TBI, history of alcohol abuse. A July 2005 VA examination report reflects the examiner, a psychiatrist, conducted a review of the claims file as part of the examination. Based on the review of the claims file and the examination of the Veteran, the examiner diagnosed psychotic disorder due to TBI. The examiner noted the evidence indicated the Veteran had a preexisting alcohol dependence problem, and he relapsed into alcohol abuse during his active service. The Veteran also had a preexisting psychotic disorder. The examiner opined it was unlikely the Veteran's preexisting mental condition was permanently aggravated by his active service, as most persons with psychotic disorders tend to have intermittent exacerbations. The examiner predicted the Veteran might have periods in the future during which he would require hospitalization again for his psychotic disorder or possibly alcohol dependence, if he relapses again. At the Board hearing, the Veteran and his representative acknowledged the two pre-service traumatic head injuries. The Veteran's representative asserted, nonetheless, that the Veteran disputed the diagnosis of schizophrenia. The Veteran's two primary contentions that emerged from the hearing are: 1) there was an exacerbation of his symptomatology in service due to his consumption of alcohol without knowledge of its potential impact on the head injury residuals; and, 2) medication administered as part of the Veteran's treatment at Walter Reed Army Medical Center (Walter Reed) aggravated the Veteran's condition. The Veteran testified he had been weaned off of the medication prior to his active service, and he was able to enlist. See Transcript, pp. 4-8. The April 2012 examination report reflects the examiner conducted a review of the claims file as part of the examination. The examiner noted Axis I diagnoses of schizophrenia and alcohol dependence in full remission. The examiner noted the Veteran's mental disorder manifested with depressed mood, flattened affect, circumstantial, circumlocutory, or stereotyped speech, intermittently illogical speech, impaired judgment, gross impairment in thought processes, difficulty in establishing and maintaining work and social relationships, and persistent delusions or hallucinations. The examiner also noted the Veteran failed to respond to nonverbal cues during a conversation. The examiner opined there was less than a 50-percent probability the Veteran's mental disorder had its onset in active service, as there was clear documentation of a 1985 diagnosis of a mental disorder. The examiner also opined the Veteran's clearly and unmistakably existed prior to active service, and it clearly and unmistakably was not aggravated beyond its natural progression. The February 2013 Board remand directed the claims file be returned to the examiner for an explanation for her opinion and comment on the medications with which the Veteran was treated at Walter Reed, and comment on any additional information developed as a result of the remand, to include whether any additional information may have changed her opinion. The July 2013 report reflects the examiner again reviewed the claims file, and she noted there was no change in her opinion rendered in April 2012. The examiner referenced, the pre-service medical evidence showing the Veteran's psychotic disorder had a pre-service onset and was variously diagnosed. The examiner noted a current diagnosis of schizophrenia. The examiner also noted the medication prescribed the Veteran as treatment was appropriate for his acquired mental disorder. The examiner noted the Veteran was treated with Stelazine/ Trifluoperazine, which medical literature notes is used for treatment of schizophrenia. As concerns her opinion the Veteran's preexisting mental disorder clearly and unmistakably was not aggravated beyond its normal progression, the examiner noted the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH EDITION (DSM-IV) notes that studies of the course and outcome with schizophrenia suggest the course may be variable, with some individuals displaying exacerbations, whereas others remain chronically ill. The examiner noted the Veteran's in-service psychotic episode may have been related to the fact the Veteran was not taking previously prescribed medication; 2) alcohol consumption, which was consistent with evidence of a pre-service alcohol-triggered psychotic episode; or, 3) the Veteran experienced an exacerbation consistent with the course of his disease. The examiner noted that there was no in-service injury, event, or illness to relate to the psychotic episode. Analysis There is no question that the Veteran has a current psychiatric disability, diagnosed as schizophrenia. The decision turns on whether the disability was incurred or aggravated in active service. Because the Veteran was not given an examination when accepted and enrolled for either period of active duty, the presumptions of soundness is not for application. Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). The evidence overwhelmingly supports a finding that the psychiatric disability pre-existed service. In addition to the pre-service treatment records showing a psychiatric disability, there are multiple medical opinions that the disability existed prior to service. These include the medical evaluation board and several VA examiners. Private treatment providers have also attributed the psychiatric disability to the TBI and alcohol abuse prior to service. These opinions were the product of an accurate and fully informed history, including examinations of the Veteran, and were supported by reasons. Hence they are sufficient to support a conclusion that the claimed psychiatric disability pre-existed service. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Service connection could still be established for the pre-existing psychiatric disability on the basis of aggravation. The July 2013, examiner provided an opinion that the current disability was not aggravated in service and that any increase was due to natural progression. The examiner based her findings and opinions on the documentation of record, and provided an explanation for her opinion. Hence, the Board finds the findings and opinion noted in the April 2012 examination report, as amplified by the July 2013 addendum, are adequate. See Nieves-Rodriguez. There is no medical opinion to the contrary. The primary evidence contrary to the medical opinions are the Veteran's contentions and testimony. Following the hearing, the representative submitted general literature to the effect that there is insufficient evidence to link an acquired mental disorder to a TBI. The Veteran's testimony that he had been unaware of the effects of alcohol use during service does not appear credible given that he was treated for alcohol problems prior to service. The November 1985 and January 1998 mental evaluation reports show an extensive pre-service history of alcohol abuse and its consequences. More importantly there is no competent medical opinion in support of the Veteran's theories of aggravation. As a lay person, he lacks the medical expertise to say that his psychiatric disability was permanently aggravated by the inadvertent use of alcohol or medications in service. The competent medical opinions are against such theories. The treatise evidence submitted by the Veteran serves only to show that TBI increases the risk of schizophrenia, but does not support any theory that the Veteran's psychiatric disability was aggravated in service. The Board finds the evidence of record shows the Veteran's psychotic disorder, to include schizophrenia, preexisted active service and that any exacerbation was due to the natural course or progression of the disorder. 38 C.F.R. § 3.306. Thus, the presumptions of in-service concurrence or aggravation under 3.307(a), and the presumption of aggravation are rebutted. Individual Unemployability A TDIU may be assigned where the combined schedular rating for the service-connected disabilities is less than 100 percent, when it is found that the service-connected disabilities render the Veteran unable to secure or follow a substantially gainful occupation. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. Unemployability associated with advancing age or intercurrent non-service-connected disability may not be considered in determining entitlement to a total compensation rating. 38 C.F.R. § 4.19. Factors to be considered are the Veteran's employment history and his educational and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). Under 38 C.F.R. § 4.16(a), if there is only one service-connected disability, the disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. The sole fact that a veteran is unemployed for non-service-connected reasons, or has difficulty obtaining employment because of economic circumstances, is not enough for a TDIU grant. A high schedular rating, in itself, is recognition that the impairment makes it difficult to obtain and retain employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can, in fact, find employment. See 38 C.F.R. §§ 4.1, 4.15. When evaluating a claim for a TDIU, the central inquiry is whether the Veteran's service-connected disabilities, alone, are of sufficient severity to produce unemployability. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). As noted, consideration may not be given to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In discussing the unemployability criteria, the Court Of Appeals For Veterans Claims (Court) has indicated that, in essence, the unemployability question, that is, the Veteran's ability or inability to engage in substantial gainful activity, has to be looked at in a practical manner, and that the thrust is whether a particular job is realistically within the capabilities, both physical and mental, of a claimant. See Moore v. Derwinski, 1 Vet. App. 83 (1991). Marginal employment shall not be considered substantially gainful employment, and generally shall be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis, when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). See Faust v. West, 13 Vet. App. 342 (2000). The VA General Counsel has concluded that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by such circumstances. Thus, the criteria include a subjective standard. It was also determined that "Unemployability" is synonymous with the inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91 (1991). In determining whether a veteran is entitled to individual unemployability, neither his nonservice-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. at 361. Thus, in deciding the claim, the Board may not favorably consider the effects of the Veteran's nonservice-connected disabilities with respect to their degree of interference with the Veteran's employability. In order for a veteran to prevail on a claim for a total compensation rating based on individual unemployability, the record must reflect some factor that takes his case outside of the norm. If total industrial impairment has not been shown, the VA is not obligated to show that a veteran is incapable of performing specific jobs in considering a claim for a total rating based on individual unemployability. See Gary v. Brown, 7 Vet. App. 229 (1994). Analysis A July 2012 rating decision reflects service connection is in effect for the following: left foot injury residuals, rated at 20-percent disabling; right foot injury residuals, rated at 10-percent disabling; and, right and left hand polyarticular pain syndrome, each rated at 10-percent disabling, for a total combined rating of 50 percent. The Veteran's total rating of 50 percent does not meet the criteria for allowance of a TDIU on a schedular basis. 38 C.F.R. § 4.16(a). The Board also notes the Veteran does not meet the criterion for multiple disabilities, that is, one must be rated at least 40-percent disabling. Id. Nonetheless, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Id. Hence, the question remains whether the Veteran's service-connected disabilities, regardless of age, prevents him from securing and following substantially gainful employment per 38 C.F.R. § 4.16(b). Rating boards are required to submit to the Director, Compensation and Pension Service (Director), for extraschedular consideration, all cases of veterans who are unemployable by reason of service-connected disability(ies), but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). 38 C.F.R. § 4.16(b). As is the case with increased rating claims, see 38 C.F.R. § 3.321(b)(1), the Court Of Appeals For Veterans Claims (Court) has held that, where a claimant does not meet the schedular requirements of 38 C.F.R. § 4.16(a), the Board has no authority to assign a total disability evaluation based on individual unemployability under 38 C.F.R. § 4.16(b). Bowling v. Principi, 15 Vet. App. 1, 10 (2001). The Board may, however, refer the claim to the Director for extraschedular consideration. The governing norm for the Board in making the determination is whether there is a plausible basis for concluding that the Veteran is unable to secure and follow a gainful occupation. Bowling, 15 Vet. App. at 9-10. The evidence of record shows the Veteran is a high school graduate, and he was only a few hours short of an associate arts degree. He last worked in 2007, when he was employed full time at IBM. The April 2012 VA general examination report reflects the examiner opined the Veteran's bilateral hand and foot disabilities did not preclude him from gainful employment. The examiner noted further that the Veteran's acquired mental disorder was his primary disability; and, the bilateral foot, in conjunction with the nonservice-connected mental disorder, would preclude the Veteran from maintaining gainful employment. (Emphasis added). Apart from the mental disorder, however, the bilateral foot disability did not preclude the Veteran from performing gainful employment. The Social Security Administration awarded the Veteran disability benefits on the basis of his acquired mental disorder. Thus, the basis of that award is readily distinguishable from the VA criteria. See Holland v. Brown, 6 Vet. App. 443, 448 (1994). In light of the above, the Board is constrained to find the preponderance of the evidence shows the Veteran's service-connected bilateral hand and bilateral foot disabilities do not render him unable to secure and follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Board finds further that the evidence shows no plausible basis for referring the Veteran's claim for consideration by the Director for unemployability on an extraschedular basis. 38 C.F.R. § 4.16(b). Thus, the Board is constrained to deny the claim. In reaching this decision the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the Veteran's claims, however, the doctrine is not for application. Schoolman v. West, 12 Vet. App. 307, 311 (1999). ORDER Entitlement to service connection for an acquired psychiatric disability, to include schizophrenia and mood disorder NOS is denied. Entitlement to a TDIU due to service-connected disabilities is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs