Citation Nr: 1537775 Decision Date: 09/03/15 Archive Date: 09/10/15 DOCKET NO. 09-37 361A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a disability rating in excess of 70 percent from October 30, 2012 for posttraumatic stress disorder (PTSD) with major depressive disorder and insomnia. 2. Entitlement to an initial compensable disability rating for onychomycosis, claimed as infected toes with toenail removal, both feet. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Delhauer, Associate Counsel INTRODUCTION The Veteran served on active duty from June 2002 to August 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2008 and December 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In April 2013, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is contained on the Virtual VA paperless claims processing system (Virtual VA). In a June 2013 decision, the Board granted entitlement to an initial disability rating of 50 percent, but no higher, for posttraumatic stress disorder (PTSD) prior to October 30, 2012, and remanded the issues above for further development. Since the issuance of the July 2013 supplemental statement of the case, additional relevant evidence has been received by VA. In a July 2015 appellate brief, the Veteran's representative waived RO consideration of this evidence. The Board observes that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits of the underlying disability. Id. at 454. In an August 2014 rating decision, the RO granted entitlement to TDIU due to the Veteran's service-connected PTSD, effective April 11, 2013, the day following the date the Veteran last worked. Accordingly, the issue of TDIU is not before the Board. Other documents contained on Virtual VA include an August 2014 rating decision, an April 2014 VA psychological examination report, and VA treatment records from the Birmingham VA Medical Center (VAMC) dated January 2007 to April 2014. The Veterans Benefits Management System (VBMS) contains records from the Social Security Administration (SSA), and a July 2015 appellate brief. Other documents contained on Virtual VA and VBMS are duplicative of the evidence of record, or are not relevant to the issues currently before the Board. FINDINGS OF FACT 1. From October 30, 2012, the Veteran's PTSD with major depressive disorder (MDD) and insomnia is manifested by symptoms resulting in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; however, total occupational and social impairment is not shown. 2. The Veteran's onychomycosis does not involve at least 5 to 20 percent of his entire body or 5 to 20 percent of the exposed areas affected, nor has it required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than 6 weeks during any 12-month period. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 70 percent from October 30, 2012, for PTSD with MDD and insomnia have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130 (2015). 2. The criteria for an initial compensable disability rating for the Veteran's service-connected onychomycosis are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.118, Diagnostic Codes 7800-7806, 7813 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of: (1) any information and medical or lay evidence that is necessary to substantiate the claim; (2) what portion of the information and evidence VA will obtain; and (3) what portion of the information and evidence the claimant is to provide. The VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided pre-adjudication VCAA notice by letter dated in April 2008. The Veteran was notified of the evidence needed to substantiate his claims of service connection for PTSD and onychomycosis, as well as what information and evidence must be submitted by the Veteran, what information and evidence would be obtained by VA, and the provisions for disability ratings and for the effective date of the claims. In cases where a compensation award has been granted and an initial disability rating and effective date have been assigned, the typical claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required, because the purpose that the notice is intended to serve has been fulfilled. See Dingess, 19 Vet. App. 473; see also VAOPGCPREC 8-2003 (December 22, 2003). Thus, because service connection for PTSD and onychomycosis have already been granted, VA's VCAA notice obligations with respect to those issues are fully satisfied, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). Duty to Assist VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the claims. Lay statements, service treatment records, VA treatment records, and SSA records have been associated with the evidentiary record. The Veteran has not identified any private medical providers. The Board notes that upon VA psychological examination in October 2012, the Veteran reported having been seen for counseling at a Vet Center several times in the past, but he could not remember the last time he was seen at the Vet Center. The Board finds that the Veteran's past Vet Center treatment records are not relevant to the issue currently before the Board, the disability rating for the Veteran's PTSD with MDD and insomnia from October 30, 2012 onward, and therefore they do not need to be obtained prior to adjudication of this issue. As part of the duty to assist, the Veteran was afforded a Board hearing pursuant to his request. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ of the Board or local decision review officer at the RO chairing a hearing fulfill two duties to comply with this VA regulation. These duties consist of (1) fully explaining the issue and (2) suggesting the submission of evidence that may have been overlooked and that may be advantageous to the claimant's position. Here, the VLJ fully explained the issues on appeal during the hearing. Additionally, it is clear from the Veteran's testimony that he had actual knowledge of the elements that were lacking to substantiate his claims. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has either identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). In the June 2013 remand, the Board instructed the AOJ to afford the Veteran a new VA examination for his onychomycosis, because the November 2012 VA examination was inadequate for rating purposes. In June 2013, the Veteran was afforded a new VA skin examination, and the VA examiner specifically addressed the percentage of the Veteran's body or exposed areas affected by his onychomycosis, as instructed by the Board. In the June 2013 remand, the Board also instructed the AOJ to afford the Veteran a new VA examination for his PTSD, as his April 2013 testimony before the Board indicated his PTSD has worsened since his October 2012 VA examination. In July 2013, the Veteran was afforded a new VA psychological examination. The Veteran was also afforded a VA psychological examination in April 2014. The June 2013, July 2013, and April 2014 VA examination reports are thorough, and discuss the clinical findings and the Veteran's reported history and symptoms as necessary to rate the disabilities under the applicable rating criteria. The July 2013 and April 2014 psychological examination reports also discuss the effects of the Veteran's PTSD symptoms on his occupational and social functioning. Based on the examinations and the absence of evidence of worsening symptomatology since the most recent examinations, the Board concludes the June 2013, July 2013, and April 2014 examination reports in this case are adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Given the June 2013 VA skin examination and report, the July 2013 VA psychological examination and report, and the subsequent readjudication of the claim in July 2013, the Board finds that there has been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Thus, with respect to the Veteran's claims, and in light of the July 2015 waiver of RO consideration of the evidence received by VA since the July 2013 supplemental statement of the case, there is no additional development that needs to be undertaken or evidence that needs to be obtained. Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Analysis The Board has thoroughly reviewed all the evidence. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). PTSD with MDD and Insomnia Rating Principles 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 adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on the social and occupational impairment, rather than solely on the examiner's assessment of the level of disability at the moment of examination. 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. Mental disorders are rated under the schedule of ratings for mental disorders, 38 C.F.R. § 4.130. In relevant part, the rating criteria are as follows: A 70 percent rating is warranted for 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 that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In evaluating psychiatric disorders, VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to the DSM. See 38 C.F.R. § 4.125(a). Effective August 4, 2014, VA amended the portion of its Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the Fourth Edition of the DSM (DSM-IV) and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014, even if such claims are subsequently remanded to the AOJ. See 80 Fed. Reg. 53, 14308 (March 19, 2015). Because the RO certified the Veteran's appeal to the Board in 2013, this claim is governed by the DSM-IV. Under the DSM-IV, diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Board notes, however, that under the DSM-5, mental health professionals, including the Veterans Health Administration, are transitioning away from using GAF scores. According to the DSM-IV, in relevant part, a GAF score between 31 and 40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A GAF score between 41 and 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). A GAF score between 51 and 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). Schedular Analysis In a December 2012 rating decision, the Veteran's PTSD was increased to 70 percent disabling, effective October 30, 2012. In a June 2013 decision, the Board granted entitlement to a disability rating of 50 percent, but no higher, for PTSD prior to October 30, 2012. The Veteran continues his appeal of the rating assigned from October 30, 2012. After reviewing the evidence of record as a whole, to include the Veteran's VA treatment records, his VA examination reports, SSA records, and the competent and credible lay statements of record, the Board finds that a disability rating in excess of 70 percent from October 30, 2012 is not warranted. Upon VA examination in October 2012, the Veteran reported that he had been married to his wife since 2011, that they had dated for two-to-three years prior to marriage, but that they had been separated for two months and his wife had filed for divorce. The Veteran stated they "just [couldn't] get along," that his wife said he has a temper and was afraid of him, he felt she did not understand, and the Veteran admitted to throwing objects or hitting doors or walls when mad. The Veteran reported he did not get along with his young stepson who lived with them, and that his wife had been keeping their young daughter away from him since the separation because she said the Veteran was too mean to her and the kids. The Veteran denied physically abusing his wife or children. The VA examiner noted the Veteran demonstrated a blunted affect and feelings of detachment. The Veteran reported that he did not get along with his parents or siblings, and that they talked one-to-two times per year. The Veteran also denied having friends or doing things socially with others since his deployment, describing himself as a loner and stating he was "pretty good" without friends. The Veteran stated he visited shooting ranges when not working, or would drive, stating he liked that he did not have to stay around people too long. Although he stated he used to enjoy fishing, working out, and hanging out with his brothers, the Veteran stated he no longer spent time with his brothers, explaining that they did not get along. The Veteran also reported that although he and his brothers previously would go home to visit his parents for Thanksgiving and Christmas, he had not participated in the past four-to-five years because he did not "feel like it." The Veteran also reported to the October 2012 VA examiner that he was currently working as a driver making furniture deliveries, and had been with the company for one year. The Veteran reported working twelve-to-fourteen hour days four-to-five days per week. The Veteran reported that his relationship with coworkers was strained because they did not get along, and that he did not really see his supervisor. Upon examination, the Veteran was cleanly and casually dressed, and unshaven but otherwise adequately groomed. The VA examiner reported that the Veteran was pleasant but remained withdrawn and guarded throughout the interview; his affect was blunted, and he did not respond to humor. The Veteran reported his mood to be anxious and nervous, and his eye contact was limited. The examiner reported the Veteran's responses were very brief and lacked detail, and that the Veteran was frequently prompted for additional information. The Veteran's speed of thinking and responding was slow, as were his physical movements. The Veteran was at times distractible, and required prompting to respond to questions; the examiner also reported the Veteran seemed to struggle with initiating tasks or instructions both on cognitive screening and informally at the end of the examination, requiring verbal and physical cues by the examiner to leave the room after the interview was over. The examiner further reported that although difficulties were observed, the Veteran's thought processes were logical and goal directed, there was no overt evidence of hallucinations or delusional thinking, and the Veteran's insight and judgment appeared to be fair. The Veteran reported his attention, concentration, and memory were "so-so," stating that lapses in attention resulted in his forgetting instructions, such as where he his driving to make a furniture delivery; such lapses in attention were noted upon examination. The Veteran struggled to recall the day of the month and the day of the week, but was eventually able to correctly recall the information; he was otherwise fully oriented to person, place, and time. The Veteran further reported that on the two days per week that he did not work, he tended to stay in bed, did not shower or change clothes, and remained in bed even though he found it hard to sleep. The Veteran endorsed feelings of helplessness, hopelessness, worthlessness, and guilt "sometimes," attributing the feelings to the fact that he did not want to be around anyone, and they did not want to be around him. The Veteran endorsed thoughts of death and admitted to active suicidal ideation in the past, but denied recent suicidal thoughts. The Veteran also endorsed significant irritability and anger on a daily basis, including being short tempered and quick to react. The Veteran reported engaging in physical fights maybe one-to-two times per month, including with family members, coworkers, and occasionally strangers in various settings. The Veteran reported his last fight occurred about a month prior. The Veteran also reported other temper outbursts, especially while driving. The Veteran reported near daily use of alcohol, approximately a pint of liquor and a few beers. The Veteran also reported a poor appetite, a low sex drive, and problems falling asleep and staying asleep. The Veteran stated he would wake every two hours due to the same dreams over and over, to include dreams of his deployment to Afghanistan three-to-four times per week. The Veteran also reported thoughts of his deployment to Afghanistan "a lot" during the days. The Veteran also reported frequent anxiety and described a near-constant uncomfortable sensation like butterflies in his stomach. The Veteran reported he would avoid going to stores because it would seem like everyone was looking at him. The Veteran also reported he would not go to sporting events or clubs because loud or unexpected noises would make him nervous. The Veteran also reported looking out the windows of his apartment repeatedly, but did not know why, and that he believed others were watching him and talking about him, though he stated he understood this is likely not the case. The Veteran reported only taking his one VA-prescribed medication once in a while, stating that it "messe[d] up [his] stomach," and that he could not wake up and get to work on time. The Veteran was not currently participating in individual or group therapy. The October 2012 VA examiner diagnosed chronic PTSD and moderate, recurrent MDD. A GAF score of 50 was assigned, and the VA examiner noted the Veteran's symptomatology appeared worse than in prior years, "likely due to recent stressors including separation and pending divorce, lack of consistent participation in [mental health] treatment, and noncompliance with psychiatric medications." The October 2012 examiner indicated the Veteran's mental diagnoses resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. In a November 2012 VA mental health telephone encounter note, the Veteran requested a letter from his treating VA psychiatrist, Dr. J.W.G., to address several issues with work regarding his diagnosis and medications. The Veteran also stated he wanted to resume medications, and the psychiatrist prescribed one for sleep and one for anxiety. The treatment note includes the letter drafted by Dr. J.W.G., indicating that the Veteran was diagnosed with PTSD and MDD, and outlining the Veteran's two prescribed medications. Dr. J.W.G. stated, "In general, [the Veteran's] overall symptom level seems relatively stable." Dr. J.W.G. noted the Veteran's history of anger, irritability, as well as arguments, and stated, "It is impossible to say with 100% certainty, but I do not believe [the Veteran] is a serious danger to himself or others at this time, including at the workplace." Upon a December 2012 VA mental health visit, Dr. J.W.G. reported the Veteran was withdrawn "as he typically is." The Veteran reported feeling down and depressed, but denied suicidal ideation. The Veteran continued to work as a truck driver, and reported that he appreciated that he could be by himself much of time, but stated he disliked having to sleep at hotels around two times per month because it caused him stress. The Veteran reported his medication for sleep did help, however he reported he stopped taking his anxiety medication after about a month because of side effects. The Veteran stated he was interested in trying a new medication, but Dr. J.W.G. noted the Veteran had experienced side effects from multiple types of medications. Upon examination the Veteran was clean and casually dressed, had poor eye contact, but his speech was at a normal rate and volume. The Veteran was alert, his thought processes were logical, but his affect was constricted, and his insight and judgment were poor. Dr. J.W.G. continued the diagnoses of PTSD and MDD, and assigned a GAF score of 55. Dr. J.W.G. prescribed a different medication for anxiety, continued the sleep medication, instructed the Veteran to return to the clinic in three months for medication follow-up and to call if any problems developed, and stated that the Veteran seemed at low risk for imminent serious self-harm or violence. Upon an April 2013 VA mental health visit, the Veteran reported stress from work, feeling that coworkers and supervisors were harassing him, and he reported he was frequently being written up for being late. The Veteran denied suicidal ideation. Dr. J.W.G. noted that the Veteran had stopped both of his medications after taking them briefly, reporting that he felt drowsy. Upon examination, the Veteran was clean and casually dressed, had poor eye contact, but his speech was at a normal rate and volume. The Veteran was alert, his thought processes were logical, but his affect was constricted, and his insight and judgment were poor. Dr. J.W.G. continued the diagnoses of PTSD and MDD, and assigned a GAF score of 55. Dr. J.W.G. recommended the Veteran try his anxiety medication again, but to take it before bed, and to continue his sleep medication on weekends. The Veteran was instructed to return to the clinic in three months for medication follow-up and to call if any problems developed, and Dr. J.W.G. stated that the Veteran seemed at low risk for imminent serious self-harm or violence. During his April 2013 hearing before the Board, the Veteran testified that he experienced nightmares, and ritualistic behaviors like having to check doors, locks, and windows. The Veteran testified that he did not like to hang out in crowds, and that he did not have a lot of friends. The Veteran stated that when he was not at work, he would not leave the house, but would clean his guns, watch television, or possibly go to the shooting range. The Veteran further testified that he and his wife were still married but lived separately, and one reason was because his wife did not feel she could live in the same house with him due to his outbreaks of rage. The Veteran reported verbal and physical altercations at work, as well as in his personal life, such as at the grocery store, but denied any legal trouble. The Veteran denied suicidal ideation, but testified he had had anger toward other people he felt were hurting him, and had thoughts of hurting or killing others at times. The Veteran also testified that his VA mental health provider would like to see him regularly, but that the Veteran had trouble getting time off from work. Upon VA examination in July 2013, the Veteran reported he had lost his job two months prior because he was told he was too slow on deliveries, he kept getting lost, and his driver's license kept being taken away due to the medications he was prescribed. The Veteran reported he had been looking for work but had not found another job yet, and had lost his house and his car. The Veteran reported staying with his parents at times and living house-to-house with different relatives, but that he was not getting along well with his relatives because they would make him mad all the time. The Veteran stated his relationship with his wife was "off and on," and that when they would try to talk they would start to fight. The Veteran reported his wife was staying with her mother, and that he would see his daughter every couple of weeks. The Veteran denied friendships or social relationships, and stated that he spent his time going to the shooting range and cleaning his six guns. The Veteran denied suicide attempts, but reported "a few" physical altercations since the October 2012 VA examination. The Veteran reported that he had planned to go back to work to shoot the people at work, but his brother took his car keys away. The Veteran reported pulling a gun on his brother, but stated that by the time he got his keys back he had changed his mind. The Veteran also reported drinking a twelve-pack of beer on most days, and sometimes drinking an entire fifth of liquor. The Veteran reported he would get the alcohol from his brother, and that sometimes they would drink it together. Upon examination, the Veteran was casually dressed and groomed, he was oriented, and his attention and concentration were intact. The VA examiner reported the Veteran made almost no eye contact, and was guarded and slumped in the chair with his back to the office door. The Veteran described his mood as mad and hopeless, and the examiner stated objectively the Veteran's mood was depressed. The Veteran's affect was sullen and blunted, and although his speech was logical, he had a long response latency, and a slowed rate of speech. The examiner stated the Veteran's thought process was difficult to assess with little verbalization, but that there was no evidence of a psychotic process. The Veteran reported problems with sleep onset and maintenance, and a reduced appetite. Regarding suicidal ideation, the Veteran reported "not today," and he reported thoughts of hurting people, as well as recent homicidal ideation with specific targets in mind. The VA examiner reported the Veteran's insight and judgment as poor. The July 2013 VA examiner diagnosed chronic PTSD, recurrent MDD, and alcohol abuse, and assigned a GAF score of 50. The VA examiner stated the Veteran had a serious impairment in functioning due to his symptoms, and opined, "It is unlikely that this Veteran will be able to find and maintain gainful employment until his mental condition is more stable. He is unlikely to be able to work at this time due to his mood disorder, PTSD, and significant alcohol abuse." The examiner stated the Veteran experienced occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The VA examiner also reported that she escorted the Veteran, along with his father, to the VA emergency department for an evaluation of the Veteran's homicidal and suicidal ideation and intent. After the July 2013 VA examination, an inpatient mental health consultation was performed in the Birmingham VAMC emergency department. The Veteran reported, "They sent me here." The VA psychiatrist, Dr. D.C.D., stated that he reviewed the Veteran's prior medical records including his mental health clinic notes. Dr. D.C.D. noted the Veteran was going through a divorce, that he visited his daughter, he lost his job, was drinking twelve beers a day, and was living with different relatives. He noted the Veteran had pulled a gun out on his brother several months prior, and that he was not taking his prescribed medications regularly. The Veteran reported insomnia, nightmares, flashbacks, irritability, difficulty being around crowds, and decreased appetite and energy. The Veteran stated he had had suicidal ideation but denied any attempts, and denied current suicidal ideation, plan, or intent; the Veteran denied homicidal ideation, plan, or intent. Upon examination by Dr. D.C.D., the Veteran was reasonably dressed and groomed, attentive, and generally cooperative, and he was alert and oriented. Dr. D.C.D. reported the Veteran's speech as fluent, with a regular rate and rhythm, and his thought process was logical and goal directed. The Veteran's mood was anxious, his affect sad, and his insight and judgment were listed as "fair/fair-to-poor." The Veteran reported having one gun in the house which was not locked or loaded; Dr. D.C.D. reported that he asked the Veteran, and the Veteran's mother on a telephone call, to remove all guns from the house. Dr. D.C.D. diagnosed PTSD, ethanol dependence, and depression not otherwise specified, and assigned a GAF score of 40. Dr. D.C.D. reported the Veteran's estimated suicide risk level as low to moderate, and the risk for homicide as low. Although Dr. D.C.D. recommended inpatient psychiatric admission, the Veteran refused. Upon the telephone call with the Veteran's mother, Dr. D.C.D. discussed a petition for the Veteran's inpatient admission, but she stated that she did not want to do so, and that she would take responsibility for the Veteran. About a week later in July 2013, the Veteran attended his scheduled VA mental health appointment with Dr. J.W.G. The Veteran was late, but reported he was doing a little bit better, and denied depressed mood, but stated his mood was not great. The Veteran clearly denied any suicidal or homicidal ideation, and denied current access to firearms. The Veteran stated that after he lost his job two months prior he "briefly thought about going over there to confront former coworkers," but he "denie[d] he was planning on shooting or killing anyone but admit[ed] he likely would have gotten into a physical confrontation if his brother hadn't intervened." The Veteran reported he was looking for another job. He also reported he stopped taking his anxiety medication due to side effects, but stated he wanted to try a different medication. Upon mental status examination, Dr. J.W.G. reported that the Veteran was clean and casually dressed, alert, his thought processes logical, and his speech had a normal rate and volume. The Veteran's eye contact was poor, his mood was "so so," his affect was blunted, and his insight and judgment were poor. Dr. J.W.G. again diagnosed PTSD and MDD, and assigned a GAF score of 55. Dr. J.W.G. switched the Veteran's anxiety medication, continued his sleep medication, and instructed the Veteran to return to the clinic in three months for medication follow-up and to call if any problems developed. Dr. J.W.G. stated that the Veteran seemed at low risk for imminent serious self-harm or violence. Upon a September 2013 VA mental health visit, the Veteran reported to Dr. J.W.G. that he was still looking for work. He admitted his anxiety level was high, but denied depressed mood, and denied suicidal or homicidal ideation. The Veteran reported he had not been taking his anxiety medication regularly partly because it was not clearly helpful, but he agreed to try a slight increase in the dose. The Veteran reported his sleep medication helped him to sleep for two-to-three hours, but then he would wake up, and at that point he would take over-the-counter Benadryl to help him go back to sleep. The Veteran stated he felt the Benadryl helped just as much as the prescription medication, and stated he was okay with switching only to Benadryl. Upon mental status examination, Dr. J.W.G. reported that the Veteran was clean and casually dressed, alert, his thought processes logical, and his speech had a normal rate and volume. The Veteran's eye contact was poor, his mood was "so so," his affect was constricted, and his insight and judgment were poor. Dr. J.W.G. again diagnosed PTSD and MDD, and assigned a GAF score of 55. Dr. J.W.G. discontinued the Veteran's sleep medication, and increased the dose of the Veteran's anxiety medication. Dr. J.W.G. noted that the Veteran declined therapy, and he instructed the Veteran to return to the clinic in December for medication follow-up and to call if any problems developed. Dr. J.W.G. stated that the Veteran seemed at low risk for imminent serious self-harm or violence. Upon the December 2013 VA mental health visit, the Veteran was 35 minutes late for his 30 minute appointment. The Veteran reported ongoing trouble with anxiety, anger, and poor sleep, but denied suicidal ideation. The Veteran reported he was only taking 1/8 of a pill of his anxiety medication instead of 1/2 because the medication upset his stomach. The Veteran agreed to try a different medication. The Veteran also reported that the Benadryl was no longer helping his sleep, and requested to restart the prescription sleep medication. Overall the Veteran's current sleep was poor. Upon mental status examination, Dr. J.W.G. reported that the Veteran was clean and casually dressed, alert, his thought processes logical, and his speech had a normal rate and volume. The Veteran's eye contact was fair, his mood was "so so," his affect was blunted, and his insight and judgment were poor. Dr. J.W.G. diagnosed PTSD, depression, and possible schizoid personality disorder. Dr. J.W.G. discontinued the Veteran's anxiety medication and prescribed a new one, and increased the dose of his sleep medication. Dr. J.W.G. instructed the Veteran to return to the clinic in March for medication follow-up and to call if any problems developed. Dr. J.W.G. stated that the Veteran seemed at low risk for imminent serious self-harm or violence. In February 2014, the Veteran walked into the VA mental health clinic with a main complaint of poor sleep, and a request to restart his prescription sleep medication. The Veteran reported side effects with his anxiety medication, but stated he wanted to resume the medication. The Veteran denied suicidal ideation. Upon mental status examination, Dr. J.W.G. reported that the Veteran was clean and casually dressed, alert, his thought processes logical, and his speech had a normal rate and volume. The Veteran's eye contact was poor, his mood was "pretty bad," his affect was constricted, and his insight and judgment were poor. Dr. J.W.G. again diagnosed PTSD and depression. Dr. J.W.G. instructed the Veteran to return to the clinic in March for medication follow-up and to call if any problems developed. Dr. J.W.G. stated that the Veteran seemed at low risk for imminent serious self-harm or violence. The Veteran's SSA records include a March 2014 report completed by the Veteran's father regarding the Veteran's functional capacity. The Veteran's father reported that the Veteran lived in an apartment with family, and that he would take care of his kids by dropping them off at school in the morning and picking them up later in the day. It was also reported by the Veteran's father that the Veteran had to be reminded to put on clean clothes, to bathe, cut and comb his hair, and to shave, and that such reminders about his personal needs and grooming were needed all day every day. It was also reported that the Veteran needed reminders to take his medications, and that the Veteran needed encouragement all the time, including to complete tasks. The Veteran's father reported that the Veteran had to be watched if he cooked because he would leave the stove on because he could not concentrate. Further, the Veteran's father reported that the Veteran would only go shopping for five to ten minutes because he did not like crowds, that the Veteran hardly goes out and stays by himself, and that the Veteran has problems getting along with people due to his anger, outbursts, and road rage. The Veteran's hobbies were reported as fishing, guns, and shooting ranges, which he would do once per week, and spending time with his father and brother once or twice a month. The Veteran's father reported that the Veteran did not get along with authority figures at all, and regarding any unusual behaviors or fears, the Veteran's father stated that the Veteran had too many guns, "like he is prepared for combat." An SSA representative also spoke with J.P., a non-relative third party, regarding the Veteran's functional capacity. J.P. stated that the Veteran slept or stayed in bed all day, but that he would care for his children with the help of his mother when the Veteran had them every other weekend. J.P. stated the Veteran was no longer able to work or be social, and that the Veteran had to be told to bathe, put on clothes, and shave, as well as reminded to go to medical appointments, take his medications, and to pick up his kids. J.P. reported the Veteran spent time with others once a week, and that he would go to the gun range weekly, but otherwise the Veteran had problems getting along with others due to his paranoia and angry outbursts, so the Veteran preferred to stay to himself and rarely socializes. J.P. further stated that the Veteran feared crowds and loud noises, did not handle stress or changes in routine well, that he was angered or irritated easily. Finally, J.P. reported that the Veteran was paranoid about police, that he could only pay attention for 20 minutes and rarely finished what he started, and that he did not follow written or spoken instructions well. Regarding his own functional capacity, the Veteran reported to SSA that he lived in an apartment with his wife mostly, that he would take his kids to school and pick them up, and that he would watch television or read during the day. The Veteran reported he was an insomniac, and hated sleep because he had bad dreams. Regarding personal care tasks, the Veteran stated he did not care about any of them, and stated he sometimes needed reminders about his personal needs, grooming, and medications. The Veteran reported that he barely did anything, but sometimes would read, watch television, hunt, or go to the gun range. The Veteran reported he did not spend time with others, that he did not get along with anyone, and he hated to be around people. The Veteran reported feeling like a prisoner in his own home, and that he did not want to go anywhere because "something bad might happen." The Veteran stated he did not handle stress well, and he would "want to hurt people." Regarding authority figures, the Veteran reported hating anyone who "think[s] they out rank me," and reported hating his last employer and being angry because they fired him because he had medical issues. On the SSA drug and alcohol questionnaire, the Veteran reported drinking every day, stated that he had no friends, that he did not want to talk to his family, and that he and his wife fight. Upon a March 2014 VA mental health visit, the Veteran stated he lost his medication bottles when his car was repossessed, but he wanted to pick up new medications. The Veteran reported being agitated and tired, but denied suicidal ideation. The Veteran admitted to drinking four-to-five drinks most days, and drinking more than six drinks about two days per week. Dr. J.W.G. stated that he advised the Veteran of the recommended limits and the need to cut down, but reported that the Veteran did not seem to think this was a problematic amount and declined treatment. Upon mental status examination, Dr. J.W.G. reported that the Veteran was clean and casually dressed, alert, his thought processes logical, and his speech had a normal rate and volume. The Veteran's eye contact was fair, his mood was "agitated," his affect was blunted, and his insight and judgment were poor. Dr. J.W.G. again diagnosed chronic PTSD and depression. Dr. J.W.G. instructed the Veteran to return to the clinic in June for medication follow-up and to call if any problems developed. Dr. J.W.G. stated that the Veteran seemed at low risk for imminent serious self-harm or violence. Upon VA examination in April 2014, the Veteran reported that he lived alone in an apartment, that he and his wife had been separated "on and off" for about three years, and that he was in a "sometimes" relationship with his wife. The Veteran stated that his wife did not understand him, and when asked, he responded he did not think he should have to understand her. The Veteran reported that the children live with his wife, and that before his car was repossessed about a month prior he would take the kids to school and pick them up. The Veteran reported that his father was "sometimes" supportive of him, and the April 2014 VA examiner noted that the Veteran's father brought him to the examination. The Veteran also reported having two friends who would come and check on him at times, and stated that he used to spend time at a shooting range and cleaning his guns, but that his mother took his guns and sold them after the July 2013 VA examination. The Veteran reported four or six physical altercations since the July 2013 VA examination, including two with adults at his daughter's day care, and stated he did not remember the others because he had been drinking. The Veteran reported he was still meeting with his VA psychiatrist on a quarterly basis, and reported that he was taking his two prescribed medications as prescribed. Further, the Veteran reported drinking four to six beers and a pint of liquor just about every day, and stated he did not consider it excessive or a problem. Upon examination, the April 2014 VA examiner reported the Veteran was casually dressed and groomed, that he displayed a slumped posture and made little eye contact. The Veteran was alert and oriented, his thought process was logical and organized, his thought content relevant, and his abstracting ability concrete. The Veteran's speech was somewhat slow, but with a normal rhythm and no spontaneous speech. His affect was blunted, he reported his mood as hopeless, and the examiner stated his mood was objectively depressed. The Veteran reported low appetite, and difficulty with onset and maintenance of sleep. The Veteran's attention and concentration were mildly impaired, his recent memory was mildly impaired, and his judgment was fair and his insight poor. The Veteran denied obsessive-compulsive traits, anxiety or panic attacks, and hallucinations; the Veteran also denied suicidal or homicidal ideation. The April 2014 VA examiner diagnosed chronic PTSD, MDD, and alcohol use disorder, and reported the Veteran's social and occupational functioning as being impaired with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The April 2014 VA examiner stated that the Veteran's functioning level had not improved since his July 2013 VA examination, and that his symptoms of PTSD with depression and alcohol abuse "make it most unlikely that he could obtain and maintain gainful employment at this time." The examiner stated that arousal symptoms and impulsivity would significantly impair any work relationships, and that impaired memory and concentration, as well as the effects of significant alcohol abuse, would impair the Veteran's ability to attend to and complete tasks, and that attendance and productivity would be markedly reduced. Following careful review of all the evidence of record, the Board finds that the Veteran's psychiatric symptoms from October 30, 2012 are commensurate with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, as contemplated by a 70 percent disability rating. See 38 C.F.R. §§ 4.7, 4.130. However, the Veteran has not demonstrated total occupational and social impairment to warrant a 100 percent rating for his psychiatric disorder. 38 C.F.R. § 4.130. Since October 30, 2012, the Veteran's service-connected PTSD with MDD and insomnia is manifested by flashbacks, nightmares, sleep problems, avoidance symptoms, depressed mood, anxiety, a restricted affect, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, a persistent inability to experience positive emotions, irritable behavior and angry outbursts, impaired impulse control, hypervigilence, problems with concentration, and mild memory loss such as forgetting names, directions, or recent events. See, e.g., April 2014 VA examination report; July 2013 VA examination report, October 2012 VA examination report. The Veteran has also described some paranoia and obsessive rituals such as checking locks and windows, however the totality of the medical evidence does not indicate these are reoccurring symptoms. See, e.g., March 2014 SSA records, April 2013 videoconference hearing testimony; October 2012 VA examination report. The evidence of record indicates the Veteran's psychological symptoms may also affect his ability to maintain his personal appearance and hygiene. See, e.g., October 2012 VA examination report. As noted in the Veteran's SSA records, the Veteran indicated he did not care about these things, and the Veteran's father and friend indicated the Veteran has to be reminded to complete personal hygiene tasks. However, the totality of the medical evidence of record does not indicate that the Veteran is unable to perform these tasks, or that he regularly neglects his personal hygiene, as all mental health providers have noted the Veteran to be groomed upon VA examination or VA mental health visits, and no mental health professionals have noted any concerns regarding the Veteran's ability to perform activities of daily living. The medical evidence of record indicates the Veteran has experienced periods of suicidal ideation. See, e.g., July 2013 VA inpatient mental health consultation; July 2013 VA examination report; October 2012 VA examination report. However, the medical evidence of record does not indicate that the Veteran is a persistent danger of harm to himself. Although the Veteran has reported suicidal ideation, since October 30, 2012, the Veteran has reported past suicidal ideation, but repeatedly denied any present suicidal thoughts. The Veteran's PTSD with MDD and insomnia is often manifested by anger and irritability, which have led to verbal altercations, physical altercations, and some homicidal ideation. Although the Veteran reported upon VA examination in October 2012 that his wife was afraid of his angry outbursts, he denied that he has ever harmed her or the children. The Veteran has reported some physical altercations upon VA examination in October 2012, July 2013, and April 2014, including with family members, co-workers, and strangers. According to the Veteran's reports, these altercations have mostly involved brief physical fights and no legal ramifications. However, during his April 2013 hearing before the Board, the Veteran admitted thoughts of anger towards others he felt were hurting him, as well as thoughts of hurting or killing others at times. Upon VA examination in July 2013, the Veteran reported pointing a gun at his brother, and homicidal ideation, including describing an incident in which he wanted to go back and shoot people at his last job after being fired. However, the Veteran stated he had changed his mind upon getting his keys back from his brother, and upon a July 2013 VA mental health visit with his treating VA psychiatrist, the Veteran denied that he was planning on shooting or killing anyone, though he admitted he likely would have gotten into a physical altercation if his brother had not intervened. Although the Veteran reported in his March 2014 SSA functional report that he would want to hurt people in response to stress, and that he did not want to go anywhere because "something bad might happen," the Veteran did not indicate that the "something bad" might be him hurting anyone. Since July 2013, the Veteran has reported that he no longer has any guns in his home, and he has repeatedly denied any homicidal ideation. See, e.g., April 2014 VA examination report; September 2013 VA mental health note; July 2013 VA mental health note. Further, the Veteran's treating VA psychiatrist, Dr. J.W.G., has repeatedly stated that the Veteran seemed at low risk for imminent serious self-harm or violence upon their quarterly meetings, and Dr. J.W.G. has not requested to see the Veteran more often, or made attempts to significantly alter the Veteran's medications except in response to the Veteran's reports of side effects. See also November 2012 VA mental health note. Considering the totality of the evidence of record, the Board finds that the Veteran experiences impaired impulse control such as unprovoked irritability with periods of violence, including occasional physical altercations, but not that he is a persistent danger of harm to others. Although the Veteran briefly described homicidal ideation toward former co-workers in the beginning of 2013, the evidence of record does not indicate that homicidal ideation or thoughts of harm to others is a recurring symptom, or that such thoughts were more than a brief reaction to the Veteran's being fired; the Veteran admitted he had no plan or intent to actually harm anyone at the former employer, and he continually denies homicidal ideation. Although the evidence indicates the Veteran does suffer from impulse control which at times has led to physical altercations, the evidence of record does not indicate that the Veteran is a persistent danger of harm to others. During the appeal period, the few reported GAF scores assigned have most often been 50 or 55, suggesting moderate to serious symptoms or moderate to serious impairment in social, occupational, or school functioning. See September 2013 VA mental health visit; July 2013 VA mental health visit; July 2013 VA examination report; April 2013 VA mental health visit; December 2012 VA mental health visit. The lowest reported GAF score of record was 40 upon the July 2013 VA inpatient mental health consultation, suggesting some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. The Board finds that the repeated GAF scores between 50 and 55, and the Veteran's competent and credible reports of his symptoms and their effect on his functioning, indicate serious symptoms, and the evidence of record indicates that such problems adversely affect his social and occupational functioning to warrant a 70 percent disability rating, but no higher. The Board finds the totality of the evidence of record indicates that the Veteran is totally occupationally impaired due to his psychological symptoms. See also August 2014 rating decision (granting entitlement to TDIU). The evidence of record indicates that the Veteran was fired from his last employer due at least in part to his problems with memory and concentration, and quite possibly due to conflicts with coworkers and supervisors. See July 2013 VA examination report; November 2012 VA mental health note. The April 2014 VA examiner opined that the Veteran's arousal symptoms and impulsivity would significantly impair any work relationships, that impaired memory and concentration, as well as the effects of significant alcohol abuse, would impair the Veteran's ability to attend to and complete tasks, and that attendance and productivity would be markedly reduced. Both the July 2013 and April 2014 VA examiners opined that the Veteran's psychological symptoms prevent the Veteran from obtaining or maintaining gainful employment at this time. However, the Board finds that the evidence of record does not indicate that the Veteran experiences total social impairment due to his PTSD with MDD and insomnia. Although the evidence of record indicates the Veteran and his wife have been separated since 2012, due at least in part to his psychological symptoms and angry outbursts, see October 2012 VA examination report, the Veteran continues to describe their relationship as "sometimes" or "off and on." See April 2014 VA examination report; July 2013 VA examination report; April 2013 videoconference hearing testimony; October 2012 VA examination report. Further, although the Veteran's wife, her son, and their daughter no longer live with the Veteran, and although the Veteran has reported he has not gotten along with his wife's son in the past, see October 2012 VA examination report, the evidence indicates the Veteran continues to drop the kids off at school and pick them up when he has a vehicle to do so, and that he visits with his daughter when possible. See April 2014 VA examination report; March 2014 SSA father and Veteran functional capacity reports; July 2013 VA examination report. The evidence of record also indicates that the Veteran has maintained relationships with family members and some friends. The Veteran has reported not wanting to talk to his family members, and that he does not get along with his parents or siblings and only sees them occasionally. See, e.g., March 2014 SSA drug and alcohol questionnaire; October 2012 VA examination report. The Veteran has also reported physical altercations with family members, such as with his brother. See July 2013 VA examination report; October 2012 VA examination report. However, the evidence of record indicates the Veteran has stayed and/or lived with his parents or various relatives, even though he stated they would make him mad all the time. See July 2013 VA examination report. The evidence also indicates the Veteran continues to see and spend time with at least one of his brothers. See July 2013 VA examination report. The evidence of record also indicates that the Veteran's parents have made attempts to help support the Veteran and help him manage his symptoms, including removing guns from the home, choosing to take responsibility for the Veteran instead of admitting him for hospitalization, driving him to examinations and appointments, and providing encouragement and reminders when necessary. See, e.g., April 2014 VA examination report; March 2014 SSA functional report completed by Veteran's father; July 2013 VA inpatient mental health consultation note; July 2013 VA examination report. Further, the Veteran's father has reported that he, the Veteran, and the Veteran's brother will go fishing, to the gun range, or otherwise spend time together at least once or twice a month. See March 2014 SSA functional report completed by Veteran's father. Further, the Veteran has denied having friends or engaging in social activities. See, e.g., March 2014 SSA functional report; July 2013 VA examination report; April 2013 videoconference hearing testimony; October 2012 VA examination report. However, the Veteran has indicated that he has at least two friends who will come and check in on him from time to time, and a March 2014 SSA record indicates that J.P. stated the Veteran spends time with others about once a week. See April 2014 VA examination report. For these reasons, the evidence of record indicates the Veteran has social impairment with deficiencies in most areas, including social and family relations, but not total social impairment, commensurate with a 70 percent rating, but no higher. Although the Veteran may meet some of the criteria for a 100 percent rating, see Mauerhan, 16 Vet. App. at 442, the Board concludes his overall level of disability does not exceed a 70 percent rating. Again, in determining that a rating in excess of 70 percent is not warranted, the Board has considered the Veteran's complaints, his VA treatment records, his SSA records, lay statements of record, and the October 2012, July 2013, and April 2014 VA examination reports, regardless of whether these symptoms are listed in the rating criteria. However, the Board concludes that the Veteran's level of social and occupational impairment does not warrant a rating in excess of 70 percent. The Board has considered the Veteran's claim and the lay and medical evidence, and concludes the evidence of record more closely approximates the criteria for a 70 percent rating for the Veteran's PTSD with MDD and insomnia from October 30, 2012. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Onychomycosis Rating Principles In the October 2008 rating decision, service connection was granted for onychomycosis, claimed as infected toes with toenail removal, both feet, rated as noncompensable under Diagnostic Code 7813. Under Diagnostic Code 7813, dermatophytosis is rated as disfigurement of the head, face, neck, scars, or dermatitis depending upon the predominant disability. The evidence of record indicates that the Veteran suffers from onychomycosis only on his feet, and does not indicate that the Veteran suffers from scars related to his onychomycosis. See, e.g., June 2013 VA examination report; November 2012 VA examination report. Therefore, the Board finds the Veteran's onychomycosis is to be rated as dermatitis, the predominant disability. Dermatitis is rated under Diagnostic Code 7806. Under this diagnostic code, a 10 percent rating is warranted for dermatitis or eczema that is at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected; or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or, systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted for more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or, constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118. (CONTINUED ON NEXT PAGE) Schedular Analysis The Veteran has stated that his feet hurt all the time, and that he is still missing toenails. See October 2009 substantive appeal; February 2009 notice of disagreement. During his April 2013 hearing before the Board, the Veteran testified that the onychomycosis affects all ten of his toes, and that during service he had all ten toenails removed, but when they grew back the problem was still there. The Veteran testified that about two times per month he has to shave down each of his toenails, and over the years he has often cut his toenails himself, as he would not get time off from work for medical appointments. The Veteran further testified that he was started on Lamisil cream for his toes, and was then switched to an oral medication, but that it does not help the condition. Finally, the Veteran testified that the pressure from his toenails on his shoes would make his toes swell, and that the swelling comes and goes. An August 2007 VA primary care outpatient note states the Veteran complained of toe pain since his active duty service when they had to remove his toenails. The primary care physician noted the Veteran had been started on Lamisil, but that it was stopped due to side effects. Thickened, crusting nails were noted upon examination. Upon a September 2007 VA podiatry consultation, the podiatrist noted the Veteran's complaints of thick toenails causing him pain when wearing shoes. Upon examination, long, thick, yellow and crumbly toenails were noted on all of the Veteran's toes. The podiatrist assessed onychomycosis, with a plan to debride the mycotic toenails, and the Veteran was to use an emery board to file his toenails on a weekly basis. The Veteran also expressed interest in a possible study for a topical antifungal medication. See also October 2007 VA podiatry note. Upon VA examination in November 2012, onychomycosis was diagnosed. The examiner noted the Veteran had been treated with topical Lamisil cream for six weeks or more, but not constant treatment; no systemic medications were reported. The November 2012 VA examiner did not report the approximate percentage of the total body area and/or the approximate total exposed body area affected by the Veteran's onychomycosis, but stated onychomycosis was present on all five toes of each foot, "with typical thickened, crumbling nail[s] that are discolored." In December 2012, the Veteran again saw a VA primary care provider; the physician noted it was the Veteran's first visit with a primary care physician in years. The Veteran requested Lamisil for his toenails. Upon examination, the physician noted onychomycosis, and diagnosed tinea unguium, or ringworm of the nails. See 38 C.F.R. § 4.118, Diagnostic Code 7813. The physician prescribed oral Lamisil tablets. See also December 2012 VA mental health note (active outpatient medications include terbinafine HCl tablets for nail fungus). Upon VA examination in June 2013, the VA examiner noted the Veteran had continued onychomycosis of all of his toenails, and that his nails were thickened and crumble. The VA examiner also noted the Veteran's complaints that he was uncomfortable in shoes because they put pressure on the thickened toe nails. The Veteran reported treatment with Lamisil for six weeks, but that it did not affect his onychomycosis. The June 2013 VA examiner specifically listed the Veteran's treatment with Lamisil for six weeks or more under the "Other oral medications" section of the Disability Benefits Questionnaire, and not as a systemic corticosteroid or other immunosuppressive medication. The June 2013 VA examiner also stated that the Veteran's onychomycosis affected less than five percent of his total body area, and did not affect any exposed area. The Veteran's SSA records include notes of contact with the Veteran by an SSA representative, in which the Veteran denied any limitations due to his onychomycosis, and the Veteran reported that the condition had "gotten much better" with treatment. See March 2014 SSA contact note; February 2014 SSA contact note. Accordingly, the Board finds that the evidence of record, including the June 2013 VA examination, indicates that less than 5 percent of the exposed area and less than 5 percent of the Veteran's total body area is affected by his onychomycosis. Further, although during the appeal period the Veteran was prescribed the systemic therapy of oral Lamisil tablets for a period of 6 weeks, the evidence of record does not indicate that such treatment has been a systemic therapy such as corticosteroids or other immunosuppressive drug. See June 2013 VA examination report. The Board finds that the evidence as a whole does not more closely approximate the criteria for a compensable rating at any time during the appeal period. The Board has also considered the Veteran's reports of foot pain and swelling of his toes associated with his onychomycosis, and that he is still missing toenails. First, the Board notes that the objective medical evidence of record does not indicate that the Veteran has been missing any toenails during the appeal period. Further, regarding the Veteran's complaints of foot pain, the Board notes the Veteran's onychomycosis is not a musculoskeletal disability, and therefore VA is not required to determine whether pain could significantly limit functional ability. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). However, the evidence of record does not indicate that the Veteran's reported foot pain or swelling due to his onychomycosis limits the functional ability of his feet or toes. Upon VA examination, both the November 2012 and June 2013 VA examiners reported no functional impact of the Veteran's onychomycosis. Further, the Veteran has not indicated that the pain or swelling impacts his functional ability, and he reported to an SSA representative in February 2014 and March 2014 that he has no functional impact from his onychomycosis. The Board acknowledges that the Veteran is competent to report on the severity of his onychomycosis. However, whether a disability meets the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on the Veteran's complaints coupled with the medical evidence of record. Both the lay and the medical evidence are probative in this case. Although the Veteran may believe that he meets the criteria for a higher disability rating for his onychomycosis, his complaints along with the medical findings do not meet the schedular requirements for a higher evaluation at any time during the appeal period, as explained and discussed above. Accordingly, the preponderance of the evidence is against assignment of an initial compensable rating for the Veteran's service-connected onychomycosis. As the greater weight of evidence is against the claim, there is no doubt on this matter that could be resolved in his favor. Extraschedular Considerations While the Board does not have authority to grant an extraschedular rating in the first instance, the Board does have the authority to decide whether the claims should be referred to the VA Director of Compensation for consideration of an extraschedular rating. 38 C.F.R. § 3.321(b)(1). The governing norm for an extraschedular rating is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or necessitated frequent periods of hospitalization so as to render the regular schedular standards impractical. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the Veteran's PTSD with MDD and insomnia is manifested by flashbacks, nightmares, sleep problems, avoidance symptoms, depressed mood, anxiety, a restricted affect, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, a persistent inability to experience positive emotions, irritable behavior and angry outbursts, impaired impulse control, hypervigilence, problems with concentration, and mild memory loss such as forgetting names, directions, or recent events. The ratings assigned contemplate these impairments. For these reasons, the disability picture is contemplated by the Rating Schedule, and the assigned schedular ratings are, therefore, adequate. Further, the Veteran's onychomycosis is manifested by pain, occasional swelling, and thickened, crumbling, discolored nails on each of his toes. The ratings assigned contemplate these impairments. For these reasons, the disability picture is contemplated by the Rating Schedule, and the assigned schedular ratings are, therefore, adequate. Accordingly, the Board has concluded that referral of this matter for extra-schedular consideration is not in order. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Under Johnson v. McDonald, 762 F.3d 1362 (2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Notably, the Veteran is only service connected for PTSD with MDD and insomnia, and onychomycosis. Neither the Veteran nor his representative has indicated any specific service-connected disabilities which are not captured by the schedular evaluations of the Veteran's individual service-connected conditions. After applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), the Board finds there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a disability rating in excess of 70 percent from October 30, 2012 for PTSD with MDD and insomnia is denied. Entitlement to an initial compensable disability rating for onychomycosis, claimed as infected toes with toenail removal, both feet, is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs