Citation Nr: 1335852 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 07-38 118 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to a disability rating higher than 70 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran served on active duty in the military from July 1968 to July 1970. He served in Vietnam and was awarded the Combat Infantryman Badge. This appeal to the Board of Veterans' Appeals (Board) is from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The RO's May 2007 rating decision denied the Veteran's claim for entitlement to an increased rating beyond 50 percent for PTSD. A subsequent March 2009 rating decision continued this denial of the PTSD claim and denied the Veteran's additional claim for a TDIU. The matter was previously before the Board in October 2011, at which time the Board rendered a decision, which granted a 70 percent disability rating for PTSD, and then remanded the issues of entitlement to a rating higher than 70 percent for PTSD and entitlement to TIDU to the RO via the Appeals Management Center (AMC) in Washington, D.C.. After completing additional development, the AMC continued to deny the claims (as reflected in a rating decision and supplemental statement of the case dated in May 2012), and returned this matter to the Board for further appellate consideration. The Board has reviewed the Veteran's claims files as well as the record maintained in the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS) to ensure complete consideration of all the evidence. The issues of entitlement to service connection for coronary artery disease, gastroesophageal reflux disease, obstructive sleep apnea, erectile disorder, neck pain, and low back pain, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). See Written Brief Presentation dated October 8, 2013. Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's PTSD does not result in total occupational and social impairment. 2. While the minimum threshold requirements for a TDIU on a schedular basis have been met, the Veteran's service-connected disabilities alone do not preclude him from obtaining and maintaining all forms of substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 70 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code (DC) 9411 (2013). 2. The criteria for a TDIU are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letters dated in January 2007 and November 2008 of the criteria for establishing an increased rating and TDIU, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates if increased entitlement is awarded. These letters accordingly addressed all notice elements and predated the initial adjudications by the AOJ/RO in May 2007 and March 2009. Nothing more was required. VA has also satisfied its duty to assist the Veteran in the development of his claims. In-service and pertinent post-service treatment reports are of record. The Veteran has availed himself of the opportunity to submit relevant evidence and argument in support of his claims. He has not indicated that any additional pertinent evidence exists, and there is no indication that any such evidence exists. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See Green v. Derwinski, 1 Vet. App. 121 (1991). Here, the Veteran was afforded VA examinations in February 2007, November 2008, June 2009, June 2011, and July 2011. To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the VA examination reports to be thorough and adequate upon which to base a decision with regard to the Veteran's claims. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his service-connected disabilities under the applicable rating criteria. The Board is also satisfied that the AMC has substantially complied with its October 2011 remand directives as they pertain to the increased rating matter decided herein. Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). A VA examination to address the severity of his PTSD was obtained in February 2012. Outstanding VA treatment records were also obtained and associated with the claims file. Thus, VA has satisfied its duty to assist the Veteran in apprising him of the evidence needed, and in obtaining evidence, to support his claims. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); & Quartuccio v. Principi, supra. II. Law and Analysis for Increased Ratings Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation [38 C.F.R. §§ 4.2, 4.41], the regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). However, where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119 (1999). The Court has also held that staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under the General Rating Formula for Mental Disorders, a 70 percent rating requires 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); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The use of the term 'such as' in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase 'such symptoms as,' followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." After considering all information and lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Service connection for PTSD was established by an October 2004 rating decision, which assigned a 50 percent disability rating under DC 9411, effective June 17, 2004. The Veteran filed his claim for increase in December 2006. In an October 2012 decision, the Board granted a 70 percent disability rating for PTSD and in a rating decision that same month, the RO assigned an effective date from the date of claim - December 11, 2006. Evidence relevant to the severity of the Veteran's service-connected PTSD includes, in addition to his assertions of increased psychiatric symptomatology, VA and Vet Center treatment records, and multiple VA examination reports, which reveal numerous GAF score assignments of 50. In connection with his claim for increase, the Veteran was afforded a VA examination in February 2007. The examiner concluded that the Veteran continued to meet the diagnostic criteria for PTSD, with symptoms including nightmares, flashbacks, intrusive thoughts about Vietnam, social isolation, sleep disturbance, irritability, decreased concentration, hyperstartle response, and depression. He also admitted to suicidal ideation, but denied any history of attempts. The Veteran had also been attending the Vet Center group therapy for the past year and had been seeing a psychiatrist on an outpatient basis for the past two years. His most recent visit was a month prior and at that time the psychiatrist indicated that the Veteran was stable psychiatrically. He had never been admitted to a psychiatric ward. In terms of his relationships with others, the Veteran had two failed marriages, but was currently dating someone and reported the relationship was going well. He endorsed having good but distant relationships with his adult children. The Veteran had been employed with the U.S. Postal Service since 1990 and prior to that had never been fired from any job. The examiner remarked that the Veteran had been able to function in his postal service job because he typically worked alone as a custodian. The Veteran indicated that he attended church regularly. On examination the Veteran was alert and oriented. His attitude was cooperative and his mood mildly depressed. His affect was constricted and occasionally tearful. He denied any suicidal or homicidal ideations. There was no evidence of paranoia or delusions. His speech was normal in rate and tone. The examiner found his PTSD produces moderate to severe impairment in social functioning and at least moderate impairment in occupational functioning. The examiner assigned a GAF score of 50. Subsequent records show the Veteran participated in an inpatient residential program for PTSD from March 31, 2008 to May 9, 2008. On admission the Veteran reported trouble sleeping due to frequent nightmares. It was also noted that he was employed full time at the US postal service for the past 16 years, but was finding it difficult to stay on his feet all the time due to pain. PTSD symptoms consistently shown in these records include sleep problems, anger, and depression. In general, these records show that the Veteran was alert, cooperative, and an active participant. He was attentive, provided feedback, and denied suicidal/homicidal ideation. During the course of his stay the Veteran showed positive progress as a participant, but continued to struggle with chronic musculoskeletal pain, depression, and sleep difficulties. He was able to successfully complete the program. At discharge he indicated plans to return to work for a short period of time to put in his paperwork for retirement. Subsequent VA outpatient treatment records show the Veteran continued with outpatient therapy for PTSD symptoms including nightmares, hypervigilance, avoidance of public places, and poor sleep. He did not think his medication was particularly helpful, but enjoyed going to the Vet Center and indicated that he had found the PTSD residential program useful. These records also show his primary concern was the excruciating lower back pain he experienced on a daily basis. It was noted that the Veteran's symptoms appeared chronic, but stable. See VA Progress Note dated August 14, 2008. As noted in the Board's October 2011 decision, VA examiners in November 2008 and June 2009 provided highly probative medical evidence in support of the notion that he meets the criteria for a 70 percent rating. Indeed, these examiners both concluded that he had deficiencies in most areas of his life, identifying his deficiencies in thinking (poor concentration); family relations (twice divorced and distant and strained relations with family); work (problems on-the-job and supervisors complained about his poor work performance); and mood (heavily depressed). These examiners also identified psychiatric symptoms appropriate to a higher 70 percent rating, including suicidal ideation, persistent panic attacks, anxious and depressive symptoms, slow speech, and flat effect. As alluded to, he appeared to have difficulty in adapting to stressful circumstances, including his former employment setting, even though he worked mostly by himself. The Veteran also showed an inability to establish and maintain effective relationships, since his family relations were strained and he considered his only social contacts to be his PTSD group therapy. On the other hand, these examination reports also note the Veteran was in daily excruciating low back pain. He also acknowledged that both the therapy and the medication helped in that the group therapy gave him a chance to express himself and the medication helped ease the pain. He continued to attend church and sometimes goes out to dinner and sometimes spends time with other Veterans outside of the Vet Center. He had a girlfriend/wife and maintained a relationship with his children. The November 2008 and June 2009 VA examiners assigned relatively low GAF scores of 45 and 43. VA outpatient treatment records dated from 2010 to 2011 are comprised primarily of records of group psychotherapy/recreational therapy sessions, medications prescribed during visits to the VA mental health clinic, and a record of behavior observed by medical staff. In general the Veteran was alert, oriented, active, and engaged with the group. These records also show periods were the Veteran was able to be cheerful and converse, laugh, and joke with peers. See Recreational Therapy Notes dated March 17, 2011 and June 30, 2011. During one particular session the Veteran was able to share that he was well respected by the kids in his neighborhood. See Psychology Note dated July 01, 2011. At a July 2011 VA examination to assess the current state of the Veteran's service-connected PTSD and its impact on his employability, the examiner interviewed the Veteran, took a detailed history of his current symptoms, and reviewed available clinical reports from treating physicians. The Veteran's psychosocial functional status since the last examination was largely unchanged. He continued to experience significant distress associated with ongoing physical health problems, including chronic pain in his back, knees, wrists, legs, as well as migraines. He noted that the pain continued to be 8-10 in severity during the day, and significantly interfered with his functional abilities. The Veteran felt his mood was more depressed due to his worsening physical and mental health symptoms and continuing functional decline. He felt more irritable and was more angry verbally, but not to the point of physical aggression or violence. He denied current suicidal ideation, plan or intent. The Veteran reported that he married some time in 2008 and that he and his wife had a good relationship. He continued to have occasional contact with his children, but felt distant from them. The Veteran continued to attend his VA therapy groups on a regular basis and had overall good relationships with fellow veterans. He indicated that his participation in these groups gets him out of the house. The Veteran had not worked since retiring from his job as a custodian in 2008 secondary to back problems. Mental status examination revealed the Veteran was neatly groomed and appropriately dressed. He was cooperative, but his attitude was detached and frustrated. Speech, thought process, and thought content were all unremarkable. His affect was constricted and his mood depressed. He had no evidence of suicidal or homicidal ideation. Attention, concentration and immediate memory were diminished, but his insight and judgment were intact. The examiner concluded that the Veteran continued to meet the diagnostic criteria for both PTSD and depression. The depression symptoms appeared primarily related to physical health problems and chronic pain coping difficulties. There was serious impairment in social engagement and family relations due to PTSD as the Veteran is detached from others and was highly irritable. However it was impossible in this examiner's opinion, to accurately separate the functional impairment associated with his depression and PTSD, as symptoms from each disorder are closely intertwined, overlapping and feeding into one another. A GAF score of 50 was assigned. In assessing his employability, the examiner concluded that it was less likely than not that being unemployable was the result of the Veteran having PTSD, alone or primarily. He noted that while the mental health symptoms did appear to contribute to some distress on the job, the Veteran was able to successfully work despite the presence of PTSD and depression symptoms for many years and retired primarily due to the presence of physical health conditions - back pain and functional limitation. The examiner noted that while the Veteran did not present as unemployable due to his mental health conditions, his symptoms would likely negatively impact his work productivity and reliability if he was otherwise able to be physically employed. Of record is a statement from the Veteran's Vet Center counselor, dated in November 2011. In this statement, the therapist offered her opinion as to the current severity of the Veteran's PTSD. She indicated that the Veteran began therapy in February 2005 and had been consistently participating in treatment since that time. Upon his initial presentation he admitted to chronic symptoms of PTSD including severe sleep disturbance, generalized anxiety, a low frustration tolerance resulting in outbursts of anger, social isolation, and depression. The Veteran was most recently evaluated for his PTSD in February 2012 as a consequence of the Board's October 2011 remand. The clinical findings on psychiatric evaluation were essentially unchanged. The Veteran reported that he continued to experience depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. The VA examiner concluded that the Veteran's PTSD was most closely manifested by occupational and social impairment with reduced reliability and productivity. Although he reported symptoms as indicated by the Veteran, he had concerns regarding the veracity of the Veteran's self-report. He opined that the Veteran was highly motivated to secure more income from the VA and that his MMPI2 results were invalid, suggesting exaggeration or over-reporting. The examiner acknowledged that the Veteran's clinical picture was a very complex one and that it was impossible to say with any certainty that any reported decline in mood or functioning was secondary to PTSD rather than his other medical difficulties. The Veteran was also found to have symptoms associated with mood disorder secondary to general medication condition and alcohol dependence in remission, in addition to symptoms of PTSD. A GAF score of 55 was assigned. A review of the remaining evidence of record shows periodic evaluation of the Veteran's PTSD as well as his increasing difficulties due to chronic pain issues, but do not otherwise indicate a significant worsening or additional symptoms to warrant a higher evaluation. In general these records show the Veteran continued to be an active participant in his therapy sessions and remained compliant with medications to help symptom management. There were no hallucinations, delusional ideas, or perceptual disturbances. See VA outpatient treatment records dated from April 2012 to August 2012. Applying the Veteran's psychiatric symptomatology to the rating criteria noted above, the Board concludes his impairment cannot be described as "total," and the record does not show the type of cognitive and behavioral impairment reserved for a 100 percent evaluation. The symptoms required for such an evaluation are neither complained of nor observed by medical health care providers, including gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Crucially, the presence of certain symptoms is not necessarily determinative. These symptoms must also cause the occupational and social impairment in the referenced areas. See Vazquez-Claudio, supra. Here, while the evidence clearly demonstrates that the Veteran has significant social and occupational impairment attributable to PTSD, his overall symptomatology is not consistent with the criteria for a 100 percent disability rating under DC 9411. Rather the relevant VA treatment records show that while the Veteran's PTSD symptoms have been continuous, he has responded favorably to treatment and as a result psychiatric symptoms have not been productive of total occupational and social impairment. Moreover, even by the Veteran's own account, his symptoms were stable and on occasion improved through the use of prescription medications and psychotherapy. The evidence clearly demonstrates periods when the Veteran is doing worse and at other times doing better. However, even at its worst, the evidence reflects a person who can function. Such findings, representing recent evidence as to the Veteran's psychiatric condition, are not consistent with increased psychiatric symptomatology reflected by the rating criteria required for the assignment of a 100 percent disability rating. In reaching this determination, the Board notes that various medical personnel, who have examined the Veteran on an outpatient basis for treatment purposes or have evaluated him to assess the nature, extent and severity of his service-connected PTSD, have estimated GAF scores between 55 and 43. Such denote moderate to serious symptoms (e.g., flat affect, and circumstantial speech, occasional panic attacks, suicidal ideation, severe obsessional rituals, frequent shoplifting) to moderate to serious impairment in social, occupational, or school functioning (e.g., few or no friends, conflicts with peers or co-workers, unable to keep a job) symptoms social and occupational functioning. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). The Board finds that these GAF scores are commensurate with the assigned 70 percent disability rating and do not provide a basis, alone, for assignment of a 100 percent rating for the Veteran's PTSD. It is also noted that the Veteran was found to have significant symptoms associated with mood disorder and alcohol dependence in addition to symptoms of PTSD. Neither disorder is service-connected, but, according to the most recent VA examiner causes some level of additional social and occupational impairment. The 2012 VA examiner, to some degree, identified the characteristics attributable to the Veteran's diagnosed psychiatric disorders. It was noted that symptoms such as anergia, lethargy, and fatigue appeared related to the Veteran's mood disorder. The Veteran was noted to be chronically negativistic, entitled, and socially unpleasant and these symptoms appeared more likely related to personality dysfunction. It was noted that while the Veteran's sleep problems may be related to PTSD, they could also be due to his diagnosed sleep apnea, which likely contributes to mood problems. The Veteran's history of alcohol dependence also likely disrupted his adjustment and worsened his existing conditions. That said, the Board has considered all of his psychiatric symptomatology in evaluating the severity of the service-connected PTSD. See Mittleider v. Brown, 11 Vet. App. 181 (1998) (which stipulates that the Board is precluded from differentiating between symptomatology attributed to a service-connected disability and another service-connected disability in the absence of medical evidence which does so). Yet, for the reasons discussed herein, the evidence of record does not warrant ratings higher than the currently-assigned 70 percent evaluation for the service-connected PTSD. The Board has carefully considered the Veteran's contentions in making this decision. However, inasmuch as the objective evidence does not otherwise substantiate the subjective complaints, his assertions do not suffice to assign higher disability rating for his service-connected PTSD. The level of disability shown is encompassed by the 70 percent rating assigned and, with due consideration to the provisions of 38 C.F.R. § 4.7, a higher 100 percent evaluation is not warranted for this disability for any portion of the time period under consideration. See Hart, supra. Consideration has also been given to the provisions of 38 C.F.R. § 3.321(b)(1), which provide for consideration of an extraschedular rating is in order when there exists such an exceptional or unusual disability picture so as to render impractical the application of the regular schedular standards. Therefore, 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 rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). The schedular evaluations in this case are not inadequate. The Veteran has not identified any factors which may be considered to be exceptional or unusual so as to render impractical the application of the regular schedular standards, and the Board has been similarly unsuccessful. As discussed above, there is a higher rating available for the Veteran's service-connected PTSD, but the required manifestations have not been shown in this case. Moreover, the evidence does not establish that this service connected disability necessitates frequent periods of hospitalization, and VA examinations are void of any finding of exceptional symptomatology beyond that contemplated by the schedule of ratings. Although the Board has no reason to doubt that the Veteran's psychiatric symptomatology adversely impacts his employability, this is specifically contemplated by the 70 percent schedular rating currently assigned. Accordingly, the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). III. Law and Analysis for TDIU The Veteran contends that his service-connected PTSD and migraine headaches render him unemployable and that he is therefore entitled to a TDIU. In this regard, the Board notes that, generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings are authorized for any disability or combination of disabilities for which the Schedule for Rating Disabilities prescribes a 100 percent disability evaluation, or, with less disability, if certain criteria are met. Id. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where a veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may not be given to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Here, the Veteran, who was last employed as a custodian in August 2008, has filed for TDIU, contending that his service-connected disabilities preclude him maintaining any sort of employment. Service connection is currently in effect for the following disabilities: PTSD rated as 70 percent disabling, migraine headaches, rated as 30 percent disabling, and bilateral tinnitus, rated as 10 percent disabling. The combined rating for the service-connected disabilities is 80 percent. Thus, the Veteran meets the minimum percentage requirements for consideration of a TDIU under 38 C.F.R. § 4.16(a). For the Veteran to prevail in a claim for TDIU, the record must reflect circumstances, apart from nonservice-connected conditions, that place him in a different position than other veterans who meet the basic schedular criteria. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Here, despite having a combined disability rating of 80 percent, the evidence does not establish that the Veteran's service-connected disabilities have rendered him unemployable. In fact, the overwhelming evidence of record shows that he retired in 2008 due to chronic low back pain after working at the post office for almost 20 years. The Board finds it significant that in his October 2008 claim for TDIU the Veteran reported being unable to secure and follow any substantially gainful occupation due to his nonservice-connected back condition. He indicated that his longest period of continuous employment was from October 1990 to August 2008 as a custodian for the post office. He last worked full time in August 2008. He finished high school and had no other education or training. See VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. However in a subsequent statement the Veteran indicated that PTSD, depression and anxiety affected his ability to work. See VA Form 21-4138, Statement in Support of Claim, received in November 2008. While it is clear that the Veteran's PTSD affects him in an occupational setting, the Board will not repeat, in its entirety, the discussion of the Veteran's psychiatric symptoms especially given that the above analysis details the level of such impairment and the appropriate disability rating to account for such impairment. However of some significance are records which show the Veteran participated in an inpatient residential program for PTSD from March 31, 2008 to May 9, 2008. It was noted at admission, the Veteran had been employed full time at the US postal service for the past 16 years, but found it difficult to stay on his feet all the time due to pain. By discharge he indicated plans to return to work for a short period of time to put in his paperwork for retirement. Shortly thereafter in August 2008 the Veteran retired from his long-standing US Postal Service employment due to low back medical problems. A VA Form 21-4192 (Request for Employment Information In Connection With Claim for Disability Benefits) shows that the Veteran was employed with post office from October 1991 to August 2008. According to the employer, the Veteran worked 40 hours a week as a custodian. This document in no way suggests that the Veteran was asked to leave because of any service-connected disability or because of excessive absence from work. It appears that the Veteran had lost no time during the 12 months preceding his last date of employment (other than during his inpatient treatment) and indicates that the reason for termination was retirement. The evidentiary record also includes a statement from a VA physician indicating the Veteran had chronic medical problems including chronic neck pain and upper extremity pain due to degenerative disc disease of the cervical spine, chronic lower back pain with associated lower extremity neuropathic pains, and upper extremity neuropathic pains due to carpal tunnel syndrome. The examiner noted that due to these chronic conditions the Veteran was totally and permanently disabled for any type of work. See medical opinion from VA staff physician dated April 19, 2011. In Apri1 2011, the Veteran submitted another VA Form 21-8940. As in the previous submission, he noted that he had last worked in 2008 as post office custodian. However on this occasion he reported that he was unable to secure and follow any substantially gainful occupation due to service-connected PTSD and migraine headaches. At a June 2011 VA examination to assess the current state of the Veteran's service-connected headaches, the examiner noted the Veteran had been under treatment for migraine headaches since 2004 according to VA records. In general, the clinical evaluation was negative for any significant problems. The examiner concluded the Veteran was a candidate for unemployability secondary to headaches noting that if the headaches occurred with considerable frequency they would hinder work flow. [Emphasis added]. In addition, the ability to concentrate on work assignment or task may be hampered with headache onset and safety concerns arise if the headaches occur while engaged in tasks requiring mental alertness. Sedentary or physical work assignments would be equally affected. At a July 2011 VA examination to assess the current state of the Veteran's service-connected PTSD and its impact on his employability, the examiner interviewed the Veteran, took a detailed history of his current symptoms, and reviewed available clinical reports from treating physicians. In assessing his employability, the examiner concluded that it was less likely than not that being unemployable was the result of the Veteran having PTSD, alone or primarily. He noted that while the mental health symptoms did appear to contribute to some distress on the job, the Veteran was able to successfully work despite the presence of PTSD and depression symptoms for many years and retired primarily due to the presence of physical health conditions - back pain and functional limitation. It was the opinion of the examiner in general that the Veteran's employability was limited, but not necessarily precluded, by both service-connected and non-service-connected disabilities. The evidence relevant to the current severity of the Veteran's migraine headaches includes a February 2012 VA examination report. At that time the examiner reviewed the claims file and noted the Veteran's complaints of headaches since 1970. The Veteran complained that it was harder to bear the pain than before and that in the last year he was seen in the emergency room 2-3 times for severe headache. He described his headaches as constant head pain localized to one side of the head and right side of his face. His non-headache symptoms included nausea, vomiting, sensitivity to light and sound, changes in vision, and facial numbness. The Veteran reported characteristic prostrating migraine headache attacks more frequently than once per month and generally last less than a day. However the Veteran also indicated that several times a year the headache may last 3-4 days. According to the Veteran, he could not do anything at the time he has a headache except lie down in a dark and quiet room and wait for it to subside. According to the Veteran, he stopped working in 2008 because of multiple medical problems including migraine headaches. The examiner did not otherwise comment on the Veteran's employability. In February 2012, the Veteran's service-connected PTSD was again evaluated. The clinical evaluation was negative for any significant problems and offered no indication that the PTSD rendered the Veteran unable to work at a substantially gainful occupation. Taking into account his education and occupational background, it cannot necessarily be concluded that the Veteran is unemployable given the current manifestations of his service-connected disabilities. The service-connected PTSD is productive of a great degree of disability, as indicated by the 70 percent rating assigned. However, there is no indication in the record that the disability involves factors that are not reflected in the Rating Schedule, or that impair the Veteran's ability to work to a greater degree than recognized. There is no indication that all employment is beyond his capacity, either in the actual performance or in moving to and from such employment. It is also clear that while the Veteran's service-connected headaches also have some negative impact on his ability to work, he has submitted no documentary evidence showing any lost time from work. Although the June 2011 VA examiner described the potential impact of the service-connected headaches on the Veteran's his ability to obtain or maintain employment, he did not specifically conclude that the migraine headaches actually precluded him from securing or following a substantially gainful occupation. Moreover, the Board finds probative the evidence of record which shows that the Veteran had been employed for almost 20 years until, by his own admission, he retired due to a low back problems. The Veteran's remaining service-connected disability, tinnitus is not significantly disabling from an industrial standpoint. There is no medical evidence of record which shows the Veteran has sought regular medical treatment for it or that it precludes him from securing or following substantially gainful employment. While the Board does not wish to minimize the nature and extent of the Veteran's overall disability, the evidence of record does not support his claim that his service-connected disabilities alone are sufficient to produce unemployability. Although they produce significant impairment, the evidence does not reflect gainful employment is precluded solely due to such service-connected disabilities. The Veteran has not identified or submitted any competent evidence, to include a medical nexus, which demonstrates that his service-connected PTSD, headaches or tinnitus, alone precludes him from securing and maintaining substantially gainful employment and entitles him to a TDIU. For all the foregoing reasons, the Board finds that the claim for entitlement to a TDIU is not warranted. 38 C.F.R. § 4.16(b). The Veteran's representative argues that VA failed to provide an adequate TDIU examination. See statement dated October 2013. Specifically, he contends that an examination was needed to address the combined effect of the Veteran's service connected disabilities. The Board does not agree. Indeed, in Geib v. Shinseki, No.2012-7164, 2013 WL XXXXXXX, at *Y (Fed. Cir. Oct. 29, 2013), the Federal Circuit held that VA's duty to assist does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities. See also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). The above described record is more than sufficient to allow the Board to make a determination on the Veteran's employability. The Board emphasizes that the ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one but rather a determination for the adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007). In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A disability rating higher than 70 percent for PTSD is denied. Entitlement to TDIU is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs