Citation Nr: 1613183 Decision Date: 03/31/16 Archive Date: 04/07/16 DOCKET NO. 10-15 549 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for rheumatoid arthritis, to include as secondary to service-connected posttraumatic stress disorder. 2. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Jones, Associate Counsel INTRODUCTION The Veteran had active military service from May 1944 to March 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2009 and May 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Colombia, South Carolina. In the May 2009 rating decision, the RO, in pertinent part, denied service connection for rheumatoid arthritis. The Veteran testified before a VA Decision Review Officer (DRO) at an August 2011 hearing conducted at the RO regarding the issue of entitlement to service connection for rheumatoid arthritis. A transcript of that hearing is of record. Thereafter, the RO denied entitlement to an increased rating for PTSD in the May 2013 rating decision. The issue of entitlement to service connection for rheumatoid arthritis was remanded by the Board for additional development in August 2013, December 2013, July 2014, and May 2015. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran's rheumatoid arthritis had its onset during military service or is otherwise related to such service or service-connected disability. 2. Throughout the rating period on appeal, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity due to symptoms such as irritability, difficulty concentrating, depressed mood, anxiety, and mild memory loss. CONCLUSIONS OF LAW 1. The criteria for service connection for rheumatoid arthritis have not been met. 38 U.S.C.A. § 1131 (West 2014); 38 C.F.R. § 3.303 (2015). 2. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS When VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Dingess/Hartman. v. Nicholson, 19 Vet. App. 473 (2006). For increased-rating claims, section 5103(a) requires the Secretary "to notify the claimant that to substantiate such a claim the claimant should provide or ask the Secretary to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment." Vazquez-Flores v. Peake, 24 Vet.App. 94, 102-03 (2010) (Vazquez-Flores v. Peake II) (citing Vazquez-Flores v. Peake, 580 F.3d 1270, 1279-80 (Fed.Cir.2009) and Vazquez-Flores v. Peake, 22 Vet.App. 37, 43 (2008)). The Veteran received notification prior to the unfavorable agency decisions in letters dated in June 2008 and March 2013. Specifically, he was apprised of information and evidence necessary to substantiate his claims. He was notified of the information and evidence that VA would seek to provide and the information and evidence that he was expected to provide. He was also informed of how VA determines disability ratings and effective dates, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Service treatment records are associated with the claims file. As requested in previous Board remands, outstanding post-service medical treatment records have also been procured. Efforts to obtain records from the Social Security Administration (SSA) were made. However, in correspondence received in August 2009 it was reported that the requested medical evidence could not be provided because the records had been destroyed. The Veteran has not identified any additional records that should be obtained prior to a Board decision. Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied. The Veteran was provided several VA examinations for his service connection claim. Pursuant to the Board's May 2015 remand directives, an additional VA examination and etiological opinion was provided in May 2015. The examination is adequate for the purposes of the service connection claim adjudicated herein, as it involved a review of the Veteran's pertinent medical history as well as a clinical evaluation of the Veteran, and provided an etiological opinion with supporting rationale. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was also afforded a VA examination in conjunction with his increased rating claim. The examination is adequate because it was based on consideration of the Veteran's pertinent medical history and described the current severity of his PTSD. Id. Thereafter, the RO issued a supplemental statement of the case in December 2015 with regard to the claim of service connection for rheumatoid arthritis. The Board finds that there has been substantial compliance with the Board's previous remand directives with regards to the issue of service connection for rheumatoid arthritis adjudicated herein. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Stegall v. West, 11 Vet. App. 268 (1998). The Board acknowledges that in the March 2016 Informal Hearing Presentation (IHP), the Veteran's representative contended that the Veteran's claim of entitlement to an increased rating for PTSD should be remanded for a more contemporaneous VA examination, as the most recent VA examination was in April 2013. The Board notes that the mere passage of time does not require that a new medical examination be provided. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007). Here, neither the Veteran nor his representative has asserted that there was a deficiency in the April 2013 VA examination. Moreover, the Veteran has not reported that the condition has worsened and no additional evidence showing a change in the severity of the service-connected PTSD has been provided since the April 2013 VA examination. The requirement that the Secretary provide a thorough and contemporaneous examination is tied to those situations where the record does not adequately reveal the current state of a claimant's disability. Therefore, the Board cannot conclude that its duty to assist in this instance requires an additional medical examination for the Veteran's service-connected PTSD. In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. I. Service Connection for Rheumatoid Arthritis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Where the veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a)-(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Factual Background Service treatment records are negative for treatment for or a diagnosis of rheumatoid arthritis during military service. Post-service VA treatment records demonstrate that the Veteran was treated for complaints of severe joint pain in March 1965. At that time, he reported that he first noted some puffiness and swelling in his fingers about 2 years prior to treatment and had a progressive increase in symptoms. Further, in December 1964 the symptoms became much worse causing swelling of the knuckles and the knees. The appellant mentioned that he was hospitalized in February 1965, where, in pertinent part, he was placed on cortisone and given steroid injections into the knees. Thereafter, he complained of severe pain when moving, to include movement of the extremities. The treating physician opined that the appellant's past history was not contributory. Severe rheumatoid arthritis was diagnosed. Subsequent private and VA medical records reveal treatment for rheumatoid arthritis and joint pain. The Veteran was provided a VA examination in November 2013. At that time, he reported that his rheumatoid arthritis symptoms started during military service. Specifically, he stated that he had intermittent pain and swelling in the knees that lasted for a few days. The symptoms got progressively worse over the years and affected his shoulders, knees, elbows, and lower back. He complained of constant soreness and intermittent daily increased pain. Following physical examination, the examiner determined that the claimed condition was less likely than not incurred in or caused by military service. In support of his opinion, the examiner noted that there was no record of treatment consistent with rheumatoid arthritis found in the appellant's service treatment records. A diagnosis was made in 1965 at which time it was noted that the onset of symptoms occurred two years earlier, which was about 17 years after separation from active military service. In the report following a March 2014 VA examination, the Veteran reported that he was diagnosed with catarrhal fever in China in 1946 and that he developed pain in the knees the same year, which increased without remission. He was diagnosed with rheumatoid arthritis in 1965 after experiencing pain in multiple joints, including the elbows, low back, and left shoulder. Following physical examination of the Veteran, the examiner opined that it was less likely than not that the condition was incurred in or caused by the claimed in-service injury, event, or illness. In support of his determination, the examiner mentioned that the service treatment records revealed "routine cat fever" from 1946 detailing a self-limited upper respiratory infection. The service treatment records did not show evidence of any signs or symptoms of inflammatory arthropathy during military service. The Veteran's rheumatoid arthritis had its onset after discharge from service and was likely not related to the single respiratory illness in service. The examiner also determined that the Veteran's rheumatoid arthritis was less likely than not proximately due to or the result of his service-connected PTSD. He reported that there was no medical rationale for causation or aggravation of rheumatoid arthritis by a purely psychiatric condition such as PTSD. In a January 2015 addendum opinion, the examiner who provided the March 2014 VA examination opined that it was less likely than not the appellant's rheumatoid arthritis was caused or aggravated by his service-connected PTSD. He noted that PTSD is a psychiatric condition and rheumatoid arthritis is an inflammatory condition. The examiner reported that there was no biomedical rational to link either diagnosis in any way. Pursuant to the Board's May 2015 remand directives, the Veteran was afforded an additional VA examination in September 2015. The examiner noted that the Veteran reported exposure to Cat Scratch fever in 1946 during military service. He was hospitalized for 4 days. Twenty years later, he was diagnosed with rheumatoid arthritis. Following examination of the Veteran, the examiner opined that the Veteran's rheumatoid arthritis was less likely than not related to his military service. She noted that the appellant's reports of diagnosis and treatment for cat scratch disease were likely unrelated to the development of rheumatoid arthritis 20 years after service for the bacterium. The examiner further noted that studies were inconclusive about the development of rheumatoid arthritis after Bartonella henselae (cat scratch disease) exposure. Therefore the claim could not be substantiated. In a December 2015 addendum opinion, the examiner opined that there was no evidence that the rheumatoid arthritis had increased beyond its natural progression. She noted that the Veteran was diagnosed with rheumatoid arthritis in 1965, was not on medication for the condition, and did not follow a rheumatologist. The examiner determined that there was no evidence in medical literature which supported the hypothesis that a mental disorder such as PTSD has a direct causal relationship with an autoimmune disease such as rheumatoid arthritis. She also opined that based on available medical literature and evidence, it was less likely as not that the appellant's rheumatoid arthritis is proximally related and/or secondary to his service-connected PTSD. In terms of progression of the disease, the examiner noted that it was theoretically possible that a medical condition which encompassed pain could be perceived as worsened in the presence of a psychological condition such as PTSD, however, such had not been documented as the case with the Veteran. The examiner noted that the Veteran' condition had remained virtually unchanged, with no medication, and not rheumatology follow-up to support a claim that rheumatoid arthritis had worsened beyond normal progression due to his service-connected PTSD. Analysis While the record demonstrates that the Veteran currently suffers from rheumatoid arthritis, the weight of the evidence is against a link between the current disability and military service. In this regard, service treatment records are negative for treatment for or a diagnosis of rheumatoid arthritis. Post-service medical records demonstrate that the appellant was diagnosed with rheumatoid arthritis in 1965. In a medical record dated in March 1965, the Veteran reported that he first noticed symptoms associated with rheumatoid arthritis two years prior to treatment. Additionally, the November 2013, March 2014, and September 2015 VA examiners determined that the condition is not related to military service. The November 2013 VA examiner noted that there was no record of treatment consistent with rheumatoid arthritis found in the appellant's service treatment records. A diagnosis was made in 1965 at which time it was noted that the onset of symptoms occurred two years earlier, which was about 17 years after separation from active military service. The March 2014 VA examiner also noted that the service treatment records did not show evidence of any signs or symptoms of inflammatory arthropathy during military service. The Veteran's rheumatoid arthritis had its onset after discharge from service and was likely not related to the single respiratory illness in service. Finally, the September 2015 VA examiner reported that the appellant's reports of diagnosis and treatment for cat scratch disease were likely unrelated to the development of rheumatoid arthritis 20 years after service for the bacterium. The examiner further noted that studies were inconclusive about the development of rheumatoid arthritis after Bartonella henselae (cat scratch disease) exposure In this regard, the Board notes that a significant lapse in time between service and post-service medical treatment may be considered, among other factors, as part of the analysis of a service connection claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Moreover, there are no other medical opinions of record relating the rheumatoid arthritis to the service. Thus, the Board finds that direct service connection for rheumatoid arthritis is not warranted. As previously noted, service-connection may be warranted if a current disability exists and was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a)-(b). However, the evidence does not suggest that rheumatoid arthritis is secondary to the Veteran's service connected PTSD. The March 2014 VA examiner opined that there was no medical rationale for causation or aggravation of rheumatoid arthritis by a purely psychiatric condition such as PTSD. In a his January 2015 addendum opinion, he further opined that it was less likely than not the rheumatoid arthritis was caused or aggravated by his service-connected PTSD. Additionally, in the December 2015 addendum opinion, the VA examiner opined that the rheumatoid arthritis was not secondary to the service-connected PTSD. To support her finding she noted that that there was no evidence in medical literature which supported a direct causal relationship with PTSD and an autoimmune disease such as rheumatoid arthritis. Moreover, there was no indication that the rheumatoid arthritis was aggravated by the service-connected PTSD. The examiner noted that the Veteran's rheumatoid arthritis had remained virtually unchanged, with no medication, and no rheumatology follow-up to support a claim that rheumatoid arthritis had worsened beyond normal progression due to PTSD. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Thus, the evidence does not support a finding of secondary service connection. The Board recognizes that arthritis is a chronic disease under 38 C.F.R. § 3.309 and, as such, presumptive service connection may be warranted. However, the evidence of record does not show that the Veteran's rheumatoid arthritis manifested to a compensable degree within one year after his discharge from service in March 1946. Notably, the evidence indicates that rheumatoid arthritis was diagnosed in 1965, 19 years after military service. As such, service connection is not warranted on the finding of a chronic disease. Additionally, presumptive service connection is not warranted on the basis of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this regard, the Veteran's asserts that he began experiencing symptoms associated with rheumatoid arthritis during military service. Specifically, he contends that he had knee pain in 1946. However, such reports are not supported by the evidence of record. Service treatment records are negative for treatment for or complaints of knee pain. Even if knee pain was present during service, the Board finds that such symptom was transient in nature. In so finding, in the March 1965 medical record, the Veteran reported that his symptoms began 2 years prior to treatment, with issues with the knees beginning in December 1964. Given these facts, service connection based on continuity of symptomatology is not warranted. The Board acknowledges the Veteran's assertion that his rheumatoid arthritis is related to military service. Although in some cases a layperson is competent to offer an opinion addressing the etiology of a disorder, the Board finds that, in this case, the determination of the origin of rheumatoid arthritis is a medical question not subject to lay expertise. See Jandreua v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The condition involves a pathological process that is not readily observable to a layperson. The Board finds that in light of the non-observable nature of the pathology, the issue of the origin of the diagnosed condition is a medical question requiring medical training, expertise and experience. In light of the foregoing, the Board finds that service connection is not warranted for the Veteran's rheumatid arthritis. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim of service for a rheumatoid arthritis must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). II. Increased Rating for PTSD Disability evaluations are determined by evaluating the extent to which a veteran's service connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2015). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2015); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Rating Criteria The Veteran's service-connected PTSD has been assigned a 50 percent rating under Diagnostic Code 9411. Under the General Rating Formula, a 50 percent evaluation will be assigned where the evidence shows occupational and social impairment with reduced reliability and productivity due to such symptoms as: a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. § 4.130, Diagnostic Code 9411 (2015). A 70 percent evaluation applies when a veteran's occupational and social impairment reflects 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned when 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; and memory loss for names of close relatives, own occupation, or own name. Id. The nomenclature employed in the rating schedule is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2015). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). However, The Board notes that a new fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (also known as "the DSM-V") has been released. This is applicable in cases pending before the RO on or after August 4, 2014, as here for the issue in question. While its predecessor, the DSM-IV, utilized GAF scores, the current DSM discards this measure and thus GAF scores will not be considered in evaluating the instant claim. 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(b). Also when evaluating mental health disorders, the factors listed in the rating criteria are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; analysis should not be limited solely to whether a Veteran exhibited the symptoms listed in the rating scheme. Rather, the determination should be based on all of a veteran's symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002); see also 38 C.F.R. § 4.126(a). Factual Background The Veteran was provided a VA examination in April 2013. At the time of the examination, it was noted that he lived with his wife of 67 years and had a good relationship with his family. The Veteran stated that at times it was overwhelming to have a lot of family come to his house. He reported that he had only a few friends and mentioned that most of his friends were deceased. Further, he tried to attend church one time per week and went out to dinner with his wife "every now and then." It was noted that the Veteran had retired from his previous employment. Additionally, the Veteran did not receive formal mental health treatment for his condition and did not take psychotropic medications. The examiner determined that the appellant's PTSD caused occupational and social impairment with reduced reliability and productivity. Symptoms of the Veteran's PTSD included recurrent and distressing recollections and dreams, intense psychological distress at exposure to internal or external cues, avoidance, markedly diminished interest or participation in significant activities, feeling of detachment, restricted range of affect, chronic sleep impairment, irritability or outburst of anger, difficulty concentrating, exaggerated startle response, depressed mood, anxiety, mild memory loss, and disturbance of motivation. It was noted that the Veteran denied any self-harm thoughts or acts. The examiner opined that the appellant reported a mild increase in PTSD symptoms since his last examination. Analysis Having considered the evidence of record, the Board finds that a rating in excess of 50 percent for PTSD is not warranted for any portion of the rating period on appeal. The Veteran exhibited symptoms of feeling of detachment, restricted range of affect, chronic sleep impairment, irritability or outburst of anger, difficulty concentrating, exaggerated startle response, depressed mood, anxiety, mild memory loss, and disturbance of motivation. Such symptomatology has been contemplated in the current 50 percent evaluation. The Board notes that it is not the individual symptoms but their overall impact on functioning that drives the evaluation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In this case, the symptoms shown have resulted in occupational and social impairment with reduced reliability and productivity, as approximated by the currently assigned 50 percent rating. As such, a higher rating is not warranted. See 38 C.F.R. § 4.130, Diagnostic Code 9411. (2015). In finding against the next-higher 70 percent rating, the evidence fails to show that the Veteran suffers from frequent obsessive rituals, hallucinations, delusions, or spatial disorientation. Moreover, there is no evidence of neglect of personal appearance and hygiene, impaired thought and judgment, speech intermittently illogical, obscure or irrelevant and near-continuous panic or depression. The appellant also denied any self-harm thoughts or acts and there was evidence of homicidal intent. The Board notes that the Veteran does not receive formal mental health treatment for his condition and does not take psychotropic medications. He also reported having a good relationship with his family, attending church, having dinner out with his wife, and having a few friends. As such, the Board finds that the symptoms demonstrated during the period on appeal have not been shown to result in occupational and social impairment with deficiencies in most areas to warrant a 70 percent rating. Extra-schedular Consideration The Board has also considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). However, this case does not present such an exceptional or unusual disability picture that it would be impracticable to apply the schedular standards, and referral is unnecessary. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Rather, the manifestations of the Veteran's PTSD are fully considered by the rating criteria. Thus, referral for consideration of an extra-schedular disability rating is not necessary at this time. See Thun, 22 Vet. App. at 115-16. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (2014), a Veteran may be awarded an extra-schedular 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. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional disabilities that have not been medically attributed to a service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for additional disability from a combined effect of multiple conditions. Individual Unemployability due to Service-connected Disabilities (TDIU) The Board acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), that a total rating based on individual unemployability, due to service-connected disability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this case, however, the record does not suggest, and the Veteran does not allege, that his PTSD has rendered him unemployable. The Board notes that the Veteran retired from his previous job, but the evidence does not indicate that it was due to his PTSD symptoms. As such, Rice is inapplicable to this case. ORDER Entitlement to service connection for rheumatoid arthritis is denied. Entitlement to rating in excess of 50 percent is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs