Citation Nr: 18143270 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 16-58 661 DATE: October 18, 2018 ORDER New and material evidence having been received, the application to reopen the claim of service connection for a neck disability is granted. New and material evidence having been received, the application to reopen the claim of service connection for a back disability is granted. Entitlement to service connection for a neck disability is denied. Entitlement to service connection for a back disability is denied. Entitlement to service connection for a bilateral shoulder disability is denied. Entitlement to a rating of 30 percent, but no higher, for service-connected adjustment disorder from February 15, 2011 to August 7, 2017 is granted. Entitlement to a rating in excess of 50 percent for service-connected adjustment disorder from August 7, 2017 is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to a service-connected disability is denied. FINDINGS OF FACT 1. In an October 1962 rating decision, the RO denied the Veteran’s claims of entitlement to service connection for disabilities of the back and neck. The Veteran did not appeal that decision, and new and material evidence was not received within one year of its issuance. 2. The evidence received since the October 1962 decision includes statements of the Veteran, VA and private treatment records, and a September 2014 private nexus opinion, which relate to unestablished facts necessary to substantiate the matters of entitlement to service connection for disabilities of the neck and back and, if presumed credible, raise a reasonable possibility of substantiating the claims. 3. The Veteran does not have a neck disability to include degenerative joint disease (DJD) that had its clinical onset in service, was manifest to a compensable degree within one year of separation from active duty, or is otherwise related to active duty. 4. The Veteran does not have a back disability to include DJD that had its clinical onset in service, was manifest to a compensable degree within one year of separation from active duty, or is otherwise related to active duty. 5. The Veteran does not have a bilateral shoulder disability to include DJD that had its clinical onset in service, was manifest to a compensable degree within one year of separation from active duty, or is otherwise related to active duty. 6. Prior to August 7, 2017, the Veteran’s service-connected adjustment disorder was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self-care, and conversation normal. 7. From the August 7, 2017, the Veteran’s service-connected adjustment disorder has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; occupational and social impairment, with deficiencies in most areas was not shown. 8. The Veteran’s service-connected disabilities, including adjustment disorder, do not preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The October 1962 RO decision denying the Veteran’s claims of service connection for disabilities of the neck and back is final. 38 U.S.C. § 7105(c) (1960); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (1962). 2. New and material evidence has been received to warrant reopening of the claims of entitlement to service connection for neck and back disabilities. 38 U.S.C. §§ 5107, 5108, 7104 (2012); 38 C.F.R. § 3.156 (2017). 3. A neck disability, to include DJD, was not incurred in or aggravated by the Veteran’s active service, and is not presumed to have been incurred in active military service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 4. A back disability, to include DJD, was not incurred in or aggravated by the Veteran’s active service, and is not presumed to have been incurred in active military service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 5. Resolving reasonable doubt in the Veteran’s favor, the criteria for a disability rating of 30 percent, but no higher, for service-connected adjustment disorder were met prior to August 7, 2017. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code (DC) 9440 (2017). 6. The criteria for a disability rating in excess of 50 percent for service-connected adjustment disorder have not been met from August 7, 2017. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.130, DC 9440 (2017). 7. The criteria for a TDIU based upon service-connected adjustment disorder are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1958 to April 1960. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated March 2014 and March 2015 of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The March 2014 rating decision granted a 10 percent rating for service-connected adjustment disorder from February 15, 2011 and assigned a zero percent rating from March 24, 2014. The March 2015 rating decision reopened and denied the Veteran’s claims of entitlement to service connection for disabilities of the back and neck; the decision also denied an original claim of service connection for a bilateral shoulder disability. During the course of the pending increased rating claim, the Veteran described an inability to retain employment due to his service-connected adjustment disorder disorder. See the Veteran’s statement dated December 2016. Thus, the question of entitlement to a TDIU has been raised and will be addressed herein. Rice v. Shinseki, 22 Vet. App. 447 (2009), (holding that a TDIU is part of an increased rating claim when raised by the record); see also VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996). In July 2018, the Veteran presented sworn testimony during a videoconference hearing, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran’s VA claims file. In a September 2018 rating decision, the RO awarded an increased rating of 50 percent for service-connected adjustment disorder from August 7, 2017. The Veteran has not expressed satisfaction with the increased disability rating; this matter thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). An August 2018 VA psychological examination report was recently added to the Veteran’s VA claims file. In October 2018, the Veteran’s representative submitted a written waiver of local consideration of this evidence; this waiver is also contained in the VA claims file. See 38 C.F.R. §§ 19.9, 20.1304(c) (2017). Claims to reopen 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a neck disability. 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for back disability. In general, decisions of the RO that are not appealed in the prescribed time period are final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. § 20.1103 (2017). Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims filed on or after August 29, 2001, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (2017). To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist. Id. at 118. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In an October 1962 rating decision, the RO denied the Veteran’s claims of entitlement to service connection for a back condition as well as traumatic neuritis of the upper spine. The Veteran did not appeal the decision. As new and material evidence was not received within one year of the decision, it became final as to the identified claim. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1100; Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). Under these circumstances, the RO’s October 1962 rating decision is final as to the Veteran’s claims of entitlement to service connection for disabilities of the back and neck, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.1103. The Veteran now seeks to reopen his claims. As noted above, despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). Thus, the Board has reviewed the entire record, with attention to the additional evidence received since the last final decision in October 1962. After reviewing the record, the Board finds that the additional evidence received is new and material within the meaning of 38 C.F.R. § 3.156 warranting reopening of the claims of service connection for back and neck disabilities. The evidence associated with the Veteran’s claims file at the time of the last final denial in October 1962 included service treatment records (STRs) and statements of the Veteran. The Veteran served on active duty from January 1958 to April 1960. STRs dated in March 1958 indicated that the Veteran complained of right flank pain after lifting his field equipment onto a locker; a diagnosis of probable mild muscular back strain was indicated. STRs dated in April 1958 noted the Veteran’s complaint of stinging pain in the thoracic region of the back. A chest x-ray conducted in September 1959 revealed “a mild, smooth kyphosis, mainly involving the dorsal spine, there are mild localized changes in this vicinity, compatible with mild stabilized Scheuerman’s disease.” A May 1959 STR indicated that the Veteran complained of back pain in the lower thoracic; an x-ray of the dorsal and lumbar spine was normal. In September 1959, the Veteran was treated for bruises and lacerations to the back and face following a fall down two flights of stairs; it was indicated that the Veteran was subsequently involved in a fight. His January 1960 separation examination did not document any continuing complaints of neck and/or back pain. As described above, based on this evidence, the Veteran’s claims of entitlement to service connection for a back disability and traumatic neuritis of the upper spine were denied in a final October 1962 RO decision. Relevant evidence received since the October 1962 decision includes VA and private treatment records, statements from the Veteran, a September 2014 opinion from Dr. H.M., and a VA examination report dated March 2015. Without the need to discuss every piece of newly received evidence in detail, the Board finds that new and material evidence has been received regarding the request to reopen the Veteran’s claims of entitlement to service connection for disabilities of the back and neck. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Namely, the September 2014 opinion from Dr. H.M. suggested a potential nexus between the Veteran’s diagnosed disabilities and his reported in-service injuries. Critically, this evidence relates to the previously unestablished element of nexus as to the back and neck disability claims. Accordingly, the standards under 3.156(a) have been met and the claims are reopened. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Shade, supra. Merits of Service Connection 3. Entitlement to service connection for a neck disability. 4. Entitlement to service connection for a back disability. 5. Entitlement to service connection for a bilateral shoulder disability. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in active service. 38 C.F.R. § 3.303(d). To establish entitlement to service connection on a direct basis, the record must contain competent evidence of (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of observable symptoms that are in his or her personal knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Id. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Here, the Veteran contends that he developed disabilities of the bilateral shoulders, neck, and back during his active duty service. See, e.g., the July 2018 Board hearing transcript. For the reasons set forth below, the Board finds that service connection is not warranted. The Veteran has asserted that he developed disabilities of the back, shoulders, and neck due to lifting heavy packs during his active duty service, as well as due to injuries sustained in an assault in which he was thrown down several flights of stairs. See, e.g., the Veteran’s statement dated December 2016. As discussed above, the Veteran’s STRs dated in March 1958 indicated that the Veteran complained of right flank pain after lifting his field equipment onto a locker; a diagnosis of probable mild muscular back strain was indicated. An STR dated in April 1958 documented the Veteran’s complaint of stinging pain in the thoracic region of the back. A chest x-ray conducted in September 1959 revealed “a mild, smooth kyphosis, mainly involving the dorsal spine, there are mild localized changes in this vicinity, compatible with mild stabilized Scheuerman’s disease.” A May 1959 STR indicated that the Veteran complained of back pain in the lower thoracic; an x-ray of the dorsal and lumbar spine was normal. In September 1959, the Veteran was treated for bruises and lacerations to the back and face following a fall down two flights of stairs with a subsequent fight. His January 1960 separation examination did not document any continuing complaints of neck, back, or bilateral shoulder pain. Private treatment records dated in August 2008 noted that the Veteran’s right shoulder “was nearly pulled out while working for Walmart.” In a separate August 2008 treatment record, the Veteran reported pain in his neck and back. VA treatment records dated in September 2010 noted that the Veteran complained of neck pain. Private treatment records dated in 2013 documented the Veteran’s report of continuing neck, back, and bilateral shoulder pain. See the private treatment records dated March 2013, May 2013, October 2013, and December 2013. In March 2014, diagnoses of spondylosis of the lumbosacral region and cervical spondylosis without myelopathy were indicated. A VA treatment record dated in May 2017 noted the Veteran’s report that he had suffered from chronic neck pain for 20 to 30 years. In support of his claims, the Veteran submitted a September 2014 letter in which his treating physician, Dr. H.M., reported that the Veteran has been a patient in his clinic since 2012 and is treated for neck, back, and shoulder pain. Dr. H.M. stated, “[t]his condition has been chronic for many years.” Dr. H.M. said that the Veteran had asked him to review service treatment records, which documented a complaint of right flank pain following a lifting injury in March 1958. Dr. H.M. opined, “it is possible that his current symptoms and conditions started from the injury in 1958 and has gotten worse with time and was exacerbated by other injuries.” The Veteran was afforded a VA examination in March 2015 at which time the examiner confirmed diagnoses of diffuse mild to moderate DJD of the cervical spine, as well as diffuse mild to moderate DJD of the lumbosacral spine. The examiner additionally diagnosed the Veteran with mild to moderate DJD of the bilateral shoulders. The examiner noted the Veteran’s report of in-service injury, as well as his description of persistent functional impairment due to his shoulder, neck, and back disabilities. The examiner provided a detailed review of the Veteran’s STRs and noted that that continuity of shoulder, back, and/or neck symptoms was not demonstrated by the medical evidence. In particular, the examiner explained that there was no documentation of injuries to the neck, back, or shoulders in the Veteran’s January 1960 separation examination and medical history assessment. The examiner then concluded, “[i]t is likely as not (50/50) that the Veteran’s shoulder, neck, and back conditions were caused by or are related to his past military service.” However, in a March 2015 addendum, the VA examiner indicated that he had misstated his conclusion; rather, he clarified, “[i]t is less likely as not (50/50) that the Veteran’s shoulder, neck, and back conditions were caused by or are related to his past military service.” The findings of the March 2015 VA examiner were thoroughly explained and fully supported by the evidence of record. To this end, the Board notes that the March 2015 VA examiner’s opinion was based on a complete review of the record, including the lay statements and treatise evidence submitted by the Veteran, and the reviewer explained the reasons for his conclusion based on an accurate characterization of the evidence of record. The Board therefore places significant weight on the findings of the March 2015 VA examiner. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). The Board has considered the September 2014 letter from Dr. H.M. noting a possibility of a link between the Veteran’s military service and his currently diagnosed disabilities of the neck, back, and shoulders. However, it is well established that medical opinions that are inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding doctor’s opinion that “it is possible” and “it is within the realm of medical possibility” too speculative to establish medical nexus); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the words “could not rule out” was too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992)(holding that a physician’s statement that a service-connected disorder “may or may not” have prevented medical personnel from averting a Veteran’s death was not sufficient). Given the applicable standard of proof, the Board finds that this evidence is insufficient to support an award of service connection and does not equal or outweigh the March 2015 VA medical opinion evidence discussed above. The Board has carefully considered the contentions of the Veteran that he suffers from disabilities of the neck, back, and shoulders, which were incurred during his military service. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran’s particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana, 24 Vet. App. at 433, n. 4. In this case, the Veteran’s assertions as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). Questions of competency notwithstanding, the Veteran’s lay theory regarding the etiology of his disabilities is contradicted by the conclusion of the March 2015 VA examiner who specifically considered the Veteran’s lay statements in rendering his negative opinion. The Board finds the specific, reasoned opinion of the trained health care provider who conducted provided the March 2015 medical opinion to be of greater probative weight than the more general lay assertions of the Veteran. The Board has considered that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Crucially, however, the Veteran’s contentions in support of service connection, including continuing post-service symptomatology of the currently diagnosed back, neck, and bilateral shoulder disabilities are contradicted by the findings of the March 2015 VA examiner who specifically considered the lay assertions and any such inferences contained in the record in rendering the negative nexus opinion. Moreover, as set forth above, the contemporaneous clinical evidence contradicts the Veteran’s contentions of continuous symptoms since service. Considering the overall evidence, including the post-service medical evidence, the VA medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran’s claims that he suffers from disabilities of the neck, back, and bilateral shoulders, which are related to his military service. Thus, the benefit-of-the-doubt rule is not applicable to the claims. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. 6. Entitlement to an increased rating for service-connected adjustment disorder, in excess of 10 percent from February 15, 2011, zero percent from March 24, 2014, and 50 percent from August 7, 2017. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claim. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the “authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence”). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) (2012) (“Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record”); 38 U.S.C. § 5107(b) (“Secretary shall consider all information and lay and medical evidence of record in a case”). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s appeal. The Veteran’s adjustment disorder is evaluated under 38 C.F.R. § 4.130, DC 9440. Under this diagnostic code, a 30 percent evaluation is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks, weekly or less often; chronic sleep impairment; and mild memory loss, such as forgetting names, directions, recent events. Id. A 50 percent evaluation is for assignment when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory, e.g., retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty establishing effective work and social relationships. Id. A 70 percent evaluation is contemplated 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 which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9440. A 100 percent evaluation is warranted when there is evidence of 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 and place; memory loss for names of close relatives, own occupation or name. Id. The GAF is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). As will be discussed below, the Veteran has been assigned GAF scores ranging from 55 to 58 as determined by treatment providers and a VA examiner. These scores are indicative of moderate impairment. A GAF score ranging from 51 to 60 reflect more 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 co-workers. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In this matter, the Veteran was granted service connection for adjustment disorder in an April 2014 rating decision; a 10 percent rating was assigned effective February 15, 2011 and a zero percent rating March 24, 2014. He disagreed with the assigned rating and this appeal followed. As described above, a September 2018 rating decision assigned a higher rating of 50 percent from August 7, 2017. For the following reasons, the Board finds that a 30 percent rating is warranted for the entire period prior to August 7, 2017 under the schedular criteria. The Board also finds that a rating in excess of 50 percent from August 7, 2017 is not warranted under the pertinent schedular criteria. VA treatment records dated in February 2011 noted that the Veteran was started on Celexa to treat his psychological symptoms. Private treatment records dated in January 2012 noted that the Veteran presented with adjustment difficulty; he reported irritability, feelings of sadness, and trouble thinking clearly. A GAF of 58 was indicated. The Veteran was afforded a VA psychological examination in March 2014 at which time the examiner confirmed a diagnosis of adjustment disorder, unspecified. The examiner stated that “[a] mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.” The Veteran reported that he had been divorced three times and has been with his current girlfriend for six years. He described his relationship with his adult son as on-going and positive. He interacts with his girlfriend’s friends. The Veteran reported no problems with social isolation. He denied trust issues and reported that he is able to connect with others. In his leisure time, he takes walks, plays bingo, and goes to the Moose Lodge. He has been retired from truck driving since 2006. He reported that, in the past, he tried to manage his psychological symptoms with medication, but could not tolerate the medication and stopped taking it after four days. The examiner explained that the Veteran “denied any significant clinical symptoms of depression or anxiety. He did report having one beer daily to deal with occasional bouts of irritability.” The examiner reported that the Veteran’s appearance was clean, neatly groomed, and casually dressed. He was well-oriented. His judgment and insight were intact. His thought content was normal. The Veteran denied suicidal and homicidal ideation. Private treatment records dated in September 2014 documented the Veteran’s report of irritability, anxiety, and easy anger. A GAF of 55 was assigned. It was further noted that the Veteran had impaired recent memory; diagnoses of minor neurocognitive disorder and anxiety disorder, not otherwise specified (NOS), were indicated. The Veteran’s private treatment provider prescribed Citalopram to manage his psychological symptoms. In November 2014, it was noted that the Veteran suffered from recurrent major depression. VA treatment records dated in July 2015 indicated that the Veteran complained of anxiety, depression, and stress. It was noted that his mood was stable. He denied suicidal and homicidal ideation. See the VA treatment records dated July 2015. The Veteran was afforded another VA psychological examination in August 2018 at which time the examiner confirmed a continuing diagnosis of adjustment disorder with mixed anxiety and depressed mood. The examiner stated that the Veteran’s psychological symptoms manifested in “[o]ccupational and social impairment with reduced reliability and productivity.” The Veteran’s girlfriend reported that the Veteran gets very upset, and is forgetful. He is thrice divorced, and continues to live with his long-time girlfriend. The Veteran last worked in 2006. He endorsed symptoms of depressed mood, anxiety, mild memory loss, difficulty in establishing and maintaining effective work and social relationships. The examiner noted that the Veteran was well-oriented and exhibited normal speech. His insight and judgment were intact. He denied suicidal and homicidal ideation. The examiner noted that the Veteran had slight depression, as well as some feelings of worthlessness. The Veteran reported that he occasionally heard voices six to seven years ago; however, he denied any current hallucinations or delusions. The Board has thoroughly reviewed the record and has given full consideration to 38 C.F.R. § 4.7 (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 required for that rating. Otherwise, the lower rating will be assigned) and 38 C.F.R. § 3.102 (when there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the veteran). In determining whether the Veteran meets the schedular criteria for an increased disability rating, the Board’s inquiry is not necessarily limited to the criteria found in the VA rating schedule. See Mauerhan, supra. Based on the above, the Board finds that the impact of the Veteran’s adjustment disorder symptoms on his social and industrial functioning is sufficient to approximate the degree of impairment contemplated by a 30 percent rating from February 15, 2011 to August 7, 2017. As detailed above, the record includes diagnoses of adjustment disorder, major depressive disorder, anxiety disorder, NOS, and minor neurocognitive disorder. Significantly the VA examiners, as well as the Veteran’s regular treatment providers have not differentiated between such symptoms and have, in fact, repeatedly described the overlapping symptoms of his psychiatric diagnoses. As such, the evidence is in equipoise as to whether the Veteran’s psychiatric symptoms are attributable to his service-connected adjustment disorder, or at least not consistently clearly separable from his service-connected disability. Mittleider v. West, 11 Vet. App. 181 (1998). Thus, all psychiatric symptoms are considered part of the service-connected diagnoses. Id. The above-described evidence reflects that, for the period prior to August 7, 2017, the Veteran’s psychiatric symptoms included anxiety, depressed mood, irritability, mild memory loss, and easy to anger. Collectively, these symptoms are of the type and extent, frequency, or severity (as appropriate), to indicate no more than the level of impairment warranting a 30 percent rating. While such symptoms are shown to have resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the Veteran was generally able to function satisfactorily with routine behavior, self-care, and normal conversation. As such, the Board finds that a rating of 30 percent is warranted under the pertinent schedular criteria prior to August 7, 2017. 38 C.F.R. § 4.130, DC 9440. Critically, the evidence demonstrates that the Veteran’s psychological symptoms prior to August 7, 2017 are, at most, indicative of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. His adjustment disorder was not shown to result in occupational and social impairment with reduced reliability and productivity at any time prior to August 7, 2017. 38 C.F.R. § 4.130, DC 9440. The Veteran maintained healthy social relationships with family and friends. He participated in activities outside of the home including going to the Moose Lodge. Moreover, although the Veteran undoubtedly experienced mood disturbances, there is no indication that his occupational and social functioning was impaired with reduced reliability and productivity prior to August 7, 2017. For the period from August 7, 2017, the Board finds that the impact of the Veteran’s adjustment disorder symptoms on his social and industrial functioning is not sufficient to approximate the degree of impairment in excess of a 50 percent rating. The evidence demonstrates that the Veteran’s psychological symptoms from August 7, 2017 have manifested as occupational and social impairment with reduced reliability and productivity due to disturbances of mood, depression, anxiety, impaired concentration, chronic sleep impairment, and difficulty in adapting to stressful circumstances, including work or a work-like setting. Critically, VA and private treatment records, as well as the VA examination reports, have not shown that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as near-continuous depression; suicidal ideation, obsessional rituals, illogical speech, near continuous panic or depression affecting the ability to function independently; spatial disorientation; neglect of personal appearance; impaired impulse control with periods of unprovoked irritability; difficulty in adapting to stressful circumstances; and the inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9440. Significantly, there is no indication that the Veteran’s occupational and social functioning was indicative of deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood at any time during the appeal period. See Vazquez-Claudio, supra. Moreover, total occupational and social impairment has not been shown at any time during the appeal period. Specifically, the evidence does not demonstrate total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; intermittent inability to perform activities of daily living; or disorientation to time or place. There is no indication of total occupational and social impairment in the record. The evidence of record does not show that the Veteran’s adjustment disorder has caused total occupational impairment. Although he was unemployed during the appeal period, the evidence does not show that the Veteran is incapable of obtaining or maintaining substantially gainful employment due to his psychological symptoms. Significantly, no medical professional has provided any opinion indicating that the Veteran’s psychological symptoms have caused total occupational impairment or an inability to obtain or maintain gainful employment. Moreover, the evidence of record does not show that the Veteran’s service-connected psychiatric disability has produced total social impairment. Accordingly, in this case, the symptoms shown in the examination and treatment records do not equate to the symptoms contemplated for a 100 percent schedular rating at any time during the appeal period. In sum, the probative evidence of record supports a finding that a rating of 30 percent, but no higher, is warranted for the Veteran’s service-connected adjustment disorder from February 15, 2011 to August 7, 2017; however, a rating in excess of 50 percent is not warranted from August 7, 2017. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55. While there may have been day-to-day fluctuations in the manifestations of the Veteran’s service-connected adjustment disorder, the evidence shows no distinct periods of time during the appeal period, when his disability varied to such an extent that a rating greater or less than the assigned ratings would be warranted. Hart, supra. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 7. Entitlement to a TDIU. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Rating Schedule provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341(a). If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. The existence or degree of nonservice connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran’s service-connected disabilities render him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). The central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19 (2016); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In this matter, the Veteran has asserted that he is unable to maintain gainful employment due to his service-connected adjustment disorder, which is his only service-connected disability. See the Veteran’s statement dated December 2016. As such, the Board will consider whether a TDIU is warranted. For the appeal period, the Board has assigned a 30 percent rating for the Veteran’s adjustment disorder from February 15, 2011 to August 7, 2017, and denied a rating in excess of 50 percent from August 7, 2017. As indicated, the Veteran has no other service-connected disabilities. Accordingly, throughout the appeal period, the Veteran has not met the minimum threshold requirements for consideration of a schedular TDIU under 38 C.F.R. § 4.16(a). The evidence of record shows that the Veteran has two Associates degrees and a Bachelor’s of Arts degree in business administration. See, e.g., the VA psychological examination report dated April 2010. He held various jobs including as a truck driver for 5 years, he then worked at a juice plant for approximately 18 years. Id. He most recently worked at Walmart until 2006. He reported that he did not retire, he just stopped working. Id. As described above, the Veteran’s medical evidence of record shows that he suffers from depression, anxiety, irritability, and mild memory loss throughout the period on appeal. To this end, the Board recognizes that the August 2017 VA examiner stated that the Veteran’s adjustment disorder manifests in “[o]ccupational and social impairment with reduced reliability and productivity.” The examiner indicated that the Veteran’s adjustment disorder cause difficulty in establishing and maintaining effective work and social relationships. However, after consideration of the entire record, the Board finds no basis for awarding a TDIU on an extraschedular evaluation for the Veteran’s service-connected adjustment disorder. While the Board acknowledges the impairment resulting from his service-connected psychological disability, the evidence does not demonstrate that this disability resulted in the Veteran’s inability to secure and follow gainful employment. In particular, the Veteran’s examination and treatment records documented mild to moderate psychological impairment. While the evidence reflects that the Veteran’s psychological disabilities limited some tasks and it does not indicate that the Veteran is unemployable. Moreover, the Veteran’s examination and treatment records did not document any periods of in-patient or intensive out-patient psychological treatment, and the Veteran did not seek emergency treatment for psychological symptoms at any time.   In conclusion, the Board finds the preponderance of the evidence to be against the award of a TDIU on any basis, and the claim must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for entitlement to TDIU must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. K. Buckley, Counsel