Citation Nr: 1807003 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 13-19 941 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for a genitourinary disability. 2. Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD) prior to October 23, 2013. 3. Entitlement to a total disability rating based on unemployability (TDIU). REPRESENTATION Veteran represented by: Mary Hoefer, Esq. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Price, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Navy from December 1964 to September 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. A February 2015 rating decision awarded a 50 percent rating for PTSD from October 23, 2013. In August 2016, the Board issued a decision denying an increased rating for the Veteran's PTSD and the Veteran appealed this decision to the Court of Appeals for Veterans Claims (Court). By a April 2017 Order, the Court, pursuant to a joint motion for remand (JMR), vacated the Board's August 2016 decision as to the period prior to October 23, 2013, and remanded the case for action consistent with the JMR. Also within the August 2016 decision, the Board reopened and remanded the claim of service connection for a genitourinary condition, along with the TDIU issue and requested the RO schedule the Veteran for another VA examination and readjudicate his claims. A VA examination was conducted in October 2016. FINDINGS OF FACT 1. The most probative evidence fails to link a current genitourinary disability to service. 2. Prior to October 23, 2013, the Veteran's PTSD was manifested by symptoms such as depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, nightmares, and disturbances of motivation and mood; all resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 3. The Veteran's service connected disabilities do not preclude him from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a genitourinary disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 2. The criteria for a rating for PTSD in excess of 30 prior to October 23, 2013 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2017). 3. The criteria for entitlement to TDIU benefits are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Genitourinary Disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 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 service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including nephritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In his claim and several statements submitted thereafter, the Veteran noted that his claimed condition was caused by the injury he suffered to his back during a motor vehicle accident (MVA) that occurred in service. The service treatment records do not reflect a diagnosis of the claimed disability, including when the genitourinary system was specifically evaluated at service separation. These records do document February 1965 complaints of sore testicles at which time the Veteran gave a history of blood in his urine twice in the last six months. He was hospitalized 4 days with a diagnosis of left varicocele. At discharge from the hospital he was excused from heavy physical exercise for 3 days and then returned to full duty. Also in service, in April 1966, as a result of a motor vehicle accident, the Veteran sustained a compression fracture of T12-L1 vertebrae, for which he is service connected. While hospitalized for this fracture (April 1 -15, 1966), he also complained of dysuria and recurrent burning with urination, but there was no hesitancy or diminution of urine stream. The burning sensation, the Veteran explained, had been intermittent since joining the Navy, but started again when hospitalized, ceasing by April 8, 1966. At the time, his prostate was found to be enlarged and there was a nodule in the left seminal vesicle area, but with no tenderness. The diagnostic impression included, "R/O urinary tract infection." No further references are made to these issues or complaints in any later service treatment record and as mentioned above, when examined in connection with his service discharge, no abnormalities of the genitourinary system were noted on clinical evaluation. A June 1968 general VA examination report revealed the Veteran indicated his only disability was a back condition; the genitourinary system was described as unremarkable. A VA examination completed in 1973 revealed a varicocele above his left testicle; but the Veteran expressed no genitourinary complaints. In July 1998, a private chiropractor, Dr. R. Brockman provided a statement discussing the Veteran's pelvic subluxation and urinary problems; he attributed both to a MVA the Veteran was involved in in January 1993. VA treatment records show the Veteran experienced a pelvic strain in February 1999. He also experienced urethral strictures and urinary tract infections twice per year, treated with antibiotics. In May 1999, the Veteran was afforded a VA genitourinary examination where severe membranous and bulbar urethral stricture was diagnosed. The Veteran described various symptoms including intermittent blockage of the urethral flow, urgency and hesitancy. As the Veteran was then contending his disorder was due to the April 1966 motor vehicle accident, the examiner addressed that contention, but did identify any link with this injury, noting the decades that elapsed before there were any strictures found, and that there was a normal cysto-urethrogram as recently as 1996. In June 1999, the Veteran underwent an urethroplasty to treat a bulbar urethral stricture. The catheter was removed in July 1999 and he reported experiencing increased urination with passage of only small amounts and dysuria. The physician treated him for a urinary tract infection (UTI). In September 1999, a treatment note indicated he had recent bladder stone removal and urethral stricture. He had a cystoscopy in March 2000, which found moderate bladder outlet obstruction due to prostatic hypertrophy; he refused treatment and became argumentative with the examining physician. Later that year in September, he returned to be examined and complained of severe pain with urination and intercourse. A retrograde urethrogram was performed and the physician noted that he was unable to determine an etiology for the Veteran's symptoms and referred him to another location for additional evaluation. In July 2001, a VA urology doctor submitted an opinion indicating that the Veteran did not suffer a urethral injury from the 1966 motorcycle accident, as there is no evidence of any urethral difficulties until 1996. He also noted that bladder stones removed in approximately 1999 were unrelated to the accident in service. In June 2002, Dr. Brockman noted that the Veteran experienced perineal reaction following the motorcycle accident in service, which caused intermittent urinary and bladder dysfunction. Another accident in 1996 resulted in pelvic subluxations and further exacerbated his symptoms. The physician provided the following opinion: "It is my professional opinion that [the Veteran's] urinary dysfunction was a result of time related deterioration of the neurological components supplying the urinary tract, which, as you know, originate in the T12, L1 dermatome area. Areas of fracture, over long periods of time, become less mobile and fixated, resulting in sclerosis and adhesions to the vascular neurological components in those areas. It is my opinion that [the Veteran] is experiencing this type of problem causing his urinary dysfunction." Dr. Brockman provided another letter in December 2008, noting that blood in the Veteran's urine following the motorcycle accident in service reinforced the idea that he experienced trauma to his pelvic region. The Veteran underwent another general VA exam in June 2011 in which the examiner reviewed the record and noted various complaints and symptoms reported by him. Ultimately, the examiner noted a diagnosis of urethral stricture that had improved via surgery since its onset in approximately 1999. In February 2012, Dr. Brockman. submitted a letter noted that the Veteran had pelvic subluxation that was not secondary to the T12-L1 fracture because they were separate issues occurring simultaneously. The physician concluded, "the pelvic distortion resulted in neurological deficiency of the urinary function, eventually causing failure of this organ." It was also noted that his pelvic subluxation improved dramatically after chiropractic treatment. During a VA examination for urinary tract conditions in June 2012, the Veteran reported recurrent kidney infections since getting out of the service in 1966. He also noted difficulties urinating and feeling bloated. He reported seeing a chiropractor in the 90s to alleviate problems with tipping in his pelvic area (he would have to tip his pelvis in order to urinate.) The examiner indicated he had voiding dysfunction due to benign prostate hyperplasia (BPH). The Veteran also experienced recurrent bladder or urethral infections that were treated with antibiotics. Ultimately, the examiner noted that the Veteran's pelvic misalignment, urethral strictures and problems urinating were not caused by or a result of his military service or due to his back condition. That conclusion was based on there being no evidence of pelvic trauma from the 1966 MVA, and the compression fractures were described as questionable at that time and as a result, there would not be any nerve trauma expected from such a minor injury. If he had a compression fracture following the accident, it was so minor so as not to cause any pelvic misalignment or nerve damage. Furthermore, the examiner found that it had completely healed and the natural history for that type of injury is to resolve without residuals. The examiner also noted that he denied any history of pelvic or penile trauma in 1996, when he first sought treatment for urinary obstruction. During the March 2016 Board hearing, the Veteran testified that he experienced a UTI in boot camp for the first time; he also had trouble urinating and with bloating. He was in the hospital for a few days in order to treat his issues. Following the motorcycle accident in 1966, he was transferred to a naval hospital and treated for pain in his back and hips. He also reported having difficulty urinating and saw blood in his urine. He also described slipping off a part of the boat and landed by straddling the prop. He was given ice and pain medication as treatment, however, afterwards, he experienced trouble going to the bathroom. His representative noted that the June 2011 examiner indicated the nerves that regulate the urethra are the same as those connected to the T11, T12 and L1 vertebrae, but there had never been a determination whether there was a connection between those nerves and the Veteran's genitourinary issues. An addendum opinion obtained in October 2016 indicated that it was less likely as not that the current urinary tract disability (including strictures and dysfunction) was related to the Veteran's military service. The examiner found that there was no nexus between the time in service and when complaints regarding recurrent UTIs first were noted in his medical record. A 1996 cysto-urethrogram showed a normal urethra and urethral strictures were not diagnosed prior to 1996. Hematuria (blood in urine) and dysuria (painful urination) are nonspecific and common complaints, which alone, are not indicative of dysfunction and strictures. Lastly, the examiner noted that the stricture was noted to be in the bulbar urethra, which is distal to the prostatic urethra; therefore, it would not be affected by a mildly enlarged prostate as noted in the 1996 urology notes. Another private opinion was obtained in August 2017 from a Dr. J.R Flanagan. He indicated that it was likely that the Veteran had a urethral catheter while he was hospitalized in 1966 based on his statements that he had to "pee in a bag" and common nursing practices at the time. Although use of a catheter was not found in the medical notes from the Veteran's hospitalization, Dr. Flanagan stated that the notes are completely devoid of any nursing documentation and in any event, a routine urinary catheter would not necessarily have been noted if unrelated to the primary concern. He indicated a urethral stricture could be caused by trauma that occurred years prior, and that such a trauma could have been caused by the placement of the catheter. (He did not, however, make any stronger statement indicating a link between a trauma caused by placement of a catheter in 1966, or other injury in-service the Veteran described, and urethral stricture first seen decades later.) He went on to conclude, however, that it was more likely than not that the Veteran's stricture was related to the urinary symptoms documented during the 1966 hospitalization. The pertinent evidence in this case may be grouped as the service treatment records, the VA medical opinions, and the non-VA medical opinions. The service treatment records carry significant probative value as they provide documentation of any in-service disease or injury to which current disability must relate in order to establish service connection. They also can inform the judgement as to whether any in-service injury or disease produced a disability. In this case, these records document urinary complaints, but fail to show the current disability, urethral stricture, including when the genitourinary system was evaluated shortly before service discharge. While clearly not dispositive of the issue of service connection, these records weigh heavily against the claim since as of September 1967, the in-service complaints did not produce a disability. Notably, service connection may be granted for any disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. Significantly, there is not much probative evidence in this file that shows a urethral stricture is the sort of disability that can have a delayed onset. Only Dr. Flanagan appears to indicate this where he advised that an injury such as could occur during the placement of a catheter (or other in-service trauma the Veteran mentioned) could later produce a stricture. However, he does not actually link this Veteran's stricture to such an injury, but instead his conclusion was that it was more likely than not the Veteran's current stricture was related to the symptoms documented in service, (i.e., dysuria and burning sensation). Because Dr. Flanagan did not go on to address how these in-service symptoms were those of a stricture in the absence of the presence of a stricture for decades, the probative weight accorded to his opinion is diminished. In addition, he does not appear to account for the post service injuries the Veteran sustained, which would seem to be potentially responsible for the disability given Dr. Flanagan's view regarding injuries and the onset of a stricture. With respect to the opinions of Dr. Brockman, because he has been inconsistent in his conclusions, his opinions are accorded little weight. He first attributed the Veteran's disability to post service injuries, and later he linked the disability to damage to nerves arising from the area of the Veteran's service connected compression fracture. The VA medical opinions are considered the most probative. Taken together they consider the Veteran's entire medical history, including the in-service complaints and findings, the many years without any complaints and the normal findings on tests conducted in the 1990's, before the current disability is seen. Following a comprehensive analysis, the conclusion was that it was unlikely the Veteran's disability was related to service. Although the cause of the Veteran's disability was not identified, that it was unlikely due to service was fully supported by the rationale expressed. In these circumstances, the Board finds the greater weight of the evidence is against the claim, and therefore, service connection for genitourinary disability is denied. II. PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. The Veteran's PTSD has been evaluated using Diagnostic Code 9411 of 38 C.F.R. § 4.130, which sets forth criteria for evaluating post-traumatic stress disorder using a general rating formula for mental disorders. Pertinent portions of the general rating formula for mental disorders are as follows: 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, mild memory loss (such as forgetting names, directions, recent events) 30 percent 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 in establishing and maintaining effective work and social relationships.....................50 percent 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........................................70 percent 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............100 percent Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-5 (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders.) Id. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. The Board notes that 38 C.F.R. § 4.130 has been revised to refer to the recently released DSM-5, which does not contain information regarding GAF scores. However, since much of the relevant evidence was obtained during the time period that the DSM-IV was in effect, the Board will still consider this information as relevant to this appeal. Furthermore, there is no indication that the Veteran's diagnosis would be different under the DSM-5. According to the DSM-IV, GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). 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); a GAF between 61 and 70 is indicative of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships; a GAF between 71 to 80 is indicative that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). The Veteran contends that his PTSD warrants a rating in excess of 30 percent prior to October 23, 2013. (In this regard, in an August 2016 decision, the Board denied a rating in excess of 50 percent for PTSD for the period after October 2013, and had denied a rating in excess of 30 percent for the period prior to October 2013. The Veteran's appeal of this decision to the Court limited the rating in dispute to the period of time prior to October 2013.) Relevant VA treatment records show the Veteran experienced several mental health symptoms including depression due to concern regarding his declining physical health. A September 2009 mental status exam was normal and indicated that he was not taking any medication for a psychiatric disability because he was worried about adverse experiences others had while on those medications. A VA examination for PTSD was conducted in February 2010 and the Veteran reported experiencing depression because of his chronic pain; he also noted feeling angry that he was not receiving better care through VA. He had trouble sleeping due to nightmares and pain; he also noted that he was no longer able to engage in certain enjoyable activities like going to bike shows or riding a motorcycle due to the pain issue. His energy level and appetite were also largely dependent on his level of pain. The Veteran was periodically seen by a psychiatrist for treatment of his chronic pain, possible somatoform disorder and anxiety/mood difficulties; however, he was not on any psychotropic medication. Psychological examination showed clear, coherent and spontaneous speech, cooperative, attentive attitude and a constricted affect. His mood was anxious, depressed and dysphoric; he was also easily distracted. His thought process was rambling but content was unremarkable, with some ruminations. There was no evidence of delusions or hallucinations. He reported being uncomfortable around children due to his experiences with Vietnamese children during service. He had no obsessive behavior, panic attacks, homicidal or suicidal thoughts. His memory was only mildly impaired, which the examiner attributed to both chronic pain and intrusive PTSD symptoms. His GAF score was 62. Overall, the examiner found that the Veteran had reduced reliability and productivity due to his PTSD symptoms. In June 2010, the Veteran indicated he was demoralized due to trying to get treatment for chronic pain associated with his disabilities. During the June 2011 PTSD VA examination, the Veteran described nightmares that caused mid-cycle awakenings, daytime fatigue, increase hypervigilance, and difficulty engaging in usual activities including work. The last occurrence was approximately eight months prior to the examination. The examiner noted that although he met the DSM-IV stressor criteria, he did not meet the criteria for a diagnosis of PTSD. Instead, the examiner diagnosed a mood disorder, nos and assigned a GAF of 61. Overall, the examiner found that the Veteran's PTSD symptoms were transient or mild and decrease work efficiency and ability to perform occupational tasks during periods of significant stress. The examiner also noted the Veteran had retired in 2002 due to multiple chronic medical conditions, especially abdominal pain. Based on the foregoing, the Board finds that the Veteran's symptoms prior to October 23, 2013, did not warrant a rating greater than 30 percent. The February 2010 VA examination showed he had constricted affect which is not a flattened affect contemplated under a 50 percent rating. Moreover, the Veteran did not have impaired abstract thinking in spite of his rambling or circumstantial thought process; though he had a non-linear thought pattern, he understood the outcome of his behavior and that he had a problem with his mental health. Furthermore, other treatment records indicated his thought process was logical, goal directed and showed intact associations. Although he reported feeling sad, down, and low, the evidence shows that some of his symptoms were due to appropriate concern regarding medical issues and his overall frustration with what he felt was inadequate care. The record does not show the Veteran has occupational and social impairment with reduced reliability and productivity due to PTSD, as the evidence points to his loss of interest and inability to perform certain activities due to his chronic pain. Furthermore, the June 2011 examiner found that he barely met the criteria for a diagnosis of PTSD; the last flare up of symptoms occurred almost eight months before the exam and the Veteran noted that since service his symptoms had gradually lessened in severity. Regarding any occupational impairment, notes from the February 2010 and June 2011 examinations revealed that he retired due to other medical conditions. Moreover, none of the examiners found that he experienced impaired judgment, insight or communication skills. In summary, although the Veteran had other symptoms i.e. anger, constricted and circumstantial speech, the Board finds that the Veteran's service-connected PTSD more nearly approximated the level of disability contemplated by the 30 percent rating. Here, the symptoms noted during the VA examinations during the appeal period are of similar severity, frequency, and duration of those noted under the criteria for a 30 percent rating. In evaluating the Veteran's increased rating claim, the Board is aware that the symptoms listed under the 30 and 50 percent ratings are essentially examples of the type and degree of symptoms for that rating, and that the Veteran need not demonstrate those exact symptoms to warrant a higher rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the Board finds that the record does not show the Veteran manifested symptoms that equal or more nearly approximate the criteria for a 50 percent prior to October 23, 2013. In making this determination, the Board notes that the Veteran was assigned GAF scores between 50 and 62, which denote moderate symptoms and are commensurate with his assigned ratings. The Board acknowledges that the Veteran, in advancing this appeal, believes that his PTSD is more severe than the assigned disability rating reflects. In this regard, he is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's description of symptoms. The lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. III. TDIU A TDIU is governed by 38 C.F.R. § 4.16, providing that such a rating may be assigned where the schedular rating is less than total, and when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, this disability shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (2015). The Veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran has 4 service connected disabilities. These are PTSD rated as 30 percent disabling prior to October 2013, and 50 percent disabling thereafter; residuals of fracture, T12-L1, evaluated as 20 percent disabling; tinnitus evaluated as 10 percent disabling; and hearing loss evaluated as non-compensably disabling. The Veteran's combined evaluation is 50 percent from 2009, and 60 percent from October 2013. As such, the Veteran does not meet the schedular requirements for an award of TDIU benefits. Further, the most probative evidence fails to show that the Veteran's service connected disabilities render him unable to obtain or maintain substantially gainful employment. VA treatment records indicate the Veteran has various medical conditions that have contributed to a decline in his health. However, only the 4 mentioned above are service connected. The record also indicates he retired, which is consistent with his current age, (he was born in 1947). A June 2011 examiner found that neither the back condition nor PTSD prevented work. There was little evidence of any residual dysfunction of any kind related to the back disability, and his mental health condition was amenable to therapy and medication, although the Veteran was unlikely to be willing to actively participate. Nevertheless, his major functional limitations were considered due to abdominal pain. The Veteran's hearing loss was considered to have no significant effects. A June 2012 examiner expressed the view the Veteran's back condition had no impact on the Veteran's ability to work, and a December 2012 examiner expressed the same view with respect to tinnitus. As the Veteran contends, his service connected disabilities must be acknowledged to interfere with his ability to work, but that is recognized by the ratings that have been assigned. These ratings do not satisfy the schedular criteria for TDIU benefits, and there have been no VA examiners who found the Veteran unemployable due to service connected disabilities. The treatment records indicate the Veteran stopped working due to non-service connected disabilities. (He also has COPD, hypertension, dysphagia, GERD and allergic rhinitis.) TDIU benefits may be awarded only where unemployability is based on service connected disabilities. As the evidence does not support the conclusion that service connected disabilities render the Veteran unable to secure or follow a substantially gainful occupation, entitlement to TDIU benefits is denied. ORDER Service connection for a genitourinary condition is denied. An increased rating for PTSD is denied. Entitlement to TDIU benefits is denied. ____________________________________________ M. E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs