Citation Nr: 1808768 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 11-15 149 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a rating in excess of 50 percent for an acquired psychiatric disorder, characterized as a depressive disorder. 2. Entitlement to an initial compensable rating for a headache disorder. 3. Entitlement to a rating in excess of 10 percent for bowel incontinence. 4. Entitlement to compensable rating for a left inguinal hernia. 5. Entitlement to compensable rating for residuals of an injury to the fifth metacarpal on the left hand. 6. Entitlement to total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Christopher N. Godios, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Meyer, Associate Counsel INTRODUCTION The Veteran had active duty service from February 2003 to June 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2008, December 2009 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, as well as a November 2011 rating decision from the RO in Cleveland, Ohio. Jurisdiction over these claims is with the RO in Cleveland, Ohio. In August 2016, the RO granted the Veteran's service connection claim for erectile dysfunction. As such, this claim is no longer on appeal. In August 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge, and a transcript of the hearing is of record. The Board acknowledges that in an August 2016 decision, the RO determined that it was clear and unmistakable error to provide the Veteran with two separate ratings for residuals of a traumatic brain injury (TBI) and a psychiatric disorder based upon the same manifestations. The Board has reviewed the record and agrees with the RO's determination. Further, given that neither the Veteran nor his attorney has raised any substantive or procedural objections with respect to the consideration of residuals of a TBI for a higher psychiatric rating, the Board will not consider this issue. Moreover, the Board finds that there is no prejudice to Veteran in failing to consider this issue as the Board has granted the Veteran's TDIU claim - which is a full grant of the benefits he requested in his June 2017 brief, and again at the August 2017 Board hearing. See AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's psychiatric disorder has been characterized by depression, anxiety, irritability, and disturbances of motivation and mood. Moreover, occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to symptoms such as obsessional rituals which interfere with routine activities, near-continuous panic or depression affecting ability to function independently, appropriately and effectively, spatial disorientation, speech that is intermittently illogical, obscure, or irrelevant, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships, have not been shown. 2. Throughout the period on appeal, the Veteran's headaches have been characterized by pain and difficulty concentrating; characteristic prostrating migraine attacks averaging one in two months over the last several months have not been shown. 3. The Veteran's bowel incontinence was characterized by occasional moderate leakage that does not require the use of pads or other appliances. 4. The Veteran's left inguinal hernia has not been shown to have required surgical intervention; or, been manifested by recurrence of an inguinal hernia, readily reducible, or well supported by truss or belt. 5. The Veteran's injury to the fifth finger on the left hand is characterized by complaints of pain. A noncompensable rating for musculoskeletal disorders to the fifth finger is the highest rating allowable, and the limitation in functioning of his fingers is not equivalent to amputation. 6. The Veteran's service-connected disabilities prevented him from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for an acquired psychiatric disorder, characterized as a depressive disorder, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9434 (2017). 2. The criteria for an initial compensable rating for a headache disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. § 4.124a, DC 8100 (2017). 3. The criteria for a rating in excess of 10 percent for a bowel disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.10, 4.14, 4.114, DC 7332 (2017). 4. The criteria for a compensable rating for a left inguinal hernia have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.114, DC 7338 (2012). 5. The criteria for a compensable rating for residuals of an injury to the fifth metacarpal on the left hand have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5230 (2017). 6. The criteria for entitlement to TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings The Veteran is seeking increased ratings for his service-connected psychiatric disorder, headache disability, bowel incontinence, left inguinal hernia, and a left finger disorder. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. While the Board typically considers only those factors contained wholly in the rating criteria, it is appropriate to consider factors outside the specific rating criteria when appropriate in order to best determine the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7 (2017). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). In the case of an initial rating, the entire evidentiary record from the time of a veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability. Fenderson v. West, 12 Vet. App. 119 (1999). However, where entitlement to compensation 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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Psychiatric Disorder The Veteran's psychiatric disorder, diagnosed as a depressive disorder, was assigned a disability rating of 50 percent under 38 C.F.R. § 4.130, DC 9434. In order to warrant a 70 percent rating, the evidence must show occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; impaired impulse control (such as unprovoked irritability with periods of violence); near-continuous panic or depression affecting ability to function independently, appropriately and effectively; spatial disorientation; speech intermittently illogical, obscure, or irrelevant; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9434. After a review of the evidence of record, the Board determines that a rating in excess of 50 percent is not warranted. Indeed, while the Veteran has occasional symptoms that could support a higher rating, the Veteran's symptoms do not otherwise cause social and occupational impairment with deficiencies in most areas of his daily living. Specifically, at a September 2009 VA examination, the Veteran appeared appropriately dressed. He endorsed symptoms of depression, anxiety, irritability, trouble sleeping, and poor concentration. On examination, he was oriented in all spheres with coherent speech and normal thought process. His judgment and insight were essentially normal. There was evidence of current suicidal/homicidal ideation, delusions, hallucinations, psychosis, or thought disorder. As such, the examiner opined that the Veteran's symptoms caused occupational and social impairment with reduced reliability and productivity. In September 2010, the Veteran presented for a treatment evaluation casually dressed. He displayed goal directed thought process with normal speech. He denied any suicidal or homicidal ideations. There was no evidence of a thought disorder or psychosis. In an October 2011 VA examination, the Veteran reported symptoms of depression, anxiety, panic attacks that occur weekly or less, sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control. On examination his speech was clear and coherent. Based upon the severity of the Veteran's symptoms, the examiner opined that the Veteran's symptoms caused "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." In an August 2013 treatment evaluation, the Veteran presented as "open minded, friendly, quick learner, and hard worker." There was no evidence of suicidal ideations, thought disorder, delusions, or a psychosis. In a December 2015 VA examination, the Veteran presented as casually and appropriately dressed with no notable grooming or hygiene deficits. He had symptoms of depressed mood, anxiety, mild memory loss, and disturbances in motivation and mood. On examination, he was attentive and cooperative with a euthymic mood and congruent affect. He displayed logical and linear goal directed thoughts. There was no evidence of a thought disorder, psychosis, hallucinations, or suicidal/homicidal ideations. The examiner opined that he Veteran's symptoms caused "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." In a December 2016 treatment evaluation, while the Veteran had symptoms of depression and anxiety, he was noted to have normal speech, goal directed thought process, and fair insight/judgment. Further, there was no evidence suicidal/homicidal ideations, psychosis, or thought disorder. In view of these clinical evaluations, the Board finds that the Veteran does not exhibit objective symptomatology that would be sufficient to warrant a rating in excess of 50 percent for the period on appeal. Specifically, the Board finds that while the Veteran stated that he has at times had thoughts of suicide, the medical evidence indicates that the Veteran had only occasional and fleeting reports of suicidal ideations that were generally characterized as passive with no intent or plan. In fact, the Veteran denied thoughts of suicide altogether at his most recent December 2015 VA examination and December 2016 VA treatment evaluation, respectively. As such, there is not sufficient evidence that the Veteran's suicidal ideations are of the severity and frequency to cause the level of occupational and social impairment associated with a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). Moreover, the Board also notes that while the Veteran exhibited some symptoms of a higher rating, including impaired impulse control, irritability, suicidal ideations, and panic attacks, VA must nevertheless engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the Veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. See Vazquez-Claudio, 713 F.3d at 115-17. In this case, the Board determines that these symptoms alone are insufficient to warrant an increased rating given the otherwise relatively mild array of symptoms and impact on the Veteran - especially in light of the fact that the Veteran displayed clear, logical, and goal oriented speech and thought processes without any signs of a psychosis, thought disorder, hallucinations, or delusions. Ultimately, many of the examples listed in the diagnostic code for a higher rating have not been shown at all. Next, although the general rating formula provides specific examples of symptoms that may result from various acquired psychiatric disorders, the Board emphasizes that its analysis should not be limited to only these symptoms, but should also consider any other relevant criteria outside of the rating code in order to determine the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). As such, the Board has also considered the extent to which there are other indications of occupational and social impairment, such as difficulty in adapting to stressful circumstances or the inability to establish and maintain effective relationships that may cause deficiencies in most areas, to include social and occupational inadaptability. In this regard, it is clear that the Veteran's disorder reflects some impact on his social and occupational functioning. Nevertheless, the evidence does not indicate that a rating in excess of 50 percent is warranted. Specifically, while the Veteran reports that he isolates himself socially, he nevertheless was able to socialize with neighbors and was able to work approximately 20 hours a week until 2016. Therefore, his level of social occupational impairment was not deficient in most areas even when factoring in other relevant criteria outside of the rating code. See Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). The Board has also considered the Veteran's Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Veteran's GAF scores reported by his private mental health providers and VA examiners were between 35 and 65. A GAF score ranging from 31-40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). On the other hand, a GAF of 41-50 would indicate "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). Finally, a GAF of 51-60 reflects "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). In this case, the Board finds that the Veteran's symptoms are most consistent with the more "moderate" symptoms reflected in a GAF score of 51 to 60, considering that while the Veteran had occasional suicidal ideations, angry outbursts, and panic attacks, such symptoms were mild, and his overall symptomatology and impact were more consistent with the moderate levels - especially given that the Veteran did not exhibit severe obsessional rituals, evidence of any psychosis, or thought disorder. Further, the Veteran's GAF scores were most consistently between 51 and 60 throughout the period on appeal. Therefore, while the Veteran's symptoms were significant, they are not so severe as to warrant a rating in excess of 50 percent. Headache Disorder The Veteran's headache disorder has been assigned an initial noncompensable evaluation under 38 C.F.R. § 4.124a, DC 8100. In order to warrant a compensable rating under this diagnostic code, the evidence must show characteristic prostrating attacks averaging one in two months over the last several months (10 percent). The rating criteria do not define "prostrating." See, e.g., Fenderson v. West, 12 Vet. App. 119 (1999). By way of reference, the Board notes that DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), defines "prostration" as "extreme exhaustion or powerlessness." In this case, the Board determines that a compensable rating is not warranted for any period on appeal. Specifically, at a VA examination in August 2008, the Veteran stated that he experiences headaches 4 times a week that last from 2 to 24 hours, and can cause nausea and vomiting. However, there was no evidence of any prostrating attacks that averaged at least one per month over the last two preceding months. In a September 2011 VA examination, while the Veteran reported a past history of headaches, he did not indicate that he was currently experiencing headaches. Further, in a September 2015 VA examination, the Veteran stated that he had headaches that lasted less than a day which caused sensitivity to light and sound. On examination, the Veteran did not have a current headache. Additionally, the examiner determined that his headaches were not characterized by prostrating attacks of migraine headache pain. Next, while the Veteran's private treatment records indicate a history of migraines and headaches, there is no indication that he suffered characteristic prostrating attacks that would warrant a compensable rating. Moreover, while the Veteran indicated that his headaches interfered with his concentration, the Board does not consider the Veteran's symptoms to reach the level of "prostrating," as contemplated by the diagnostic code as the evidence does not indicate that he is physically helpless due to his headaches. Therefore, a compensable rating is not warranted for his headaches. Bowel Disorder The Veteran's bowel disorder has been assigned a 10 percent rating under 38 C.F.R. § 4.114, DC 7332. In order to warrant a 20 percent rating under this diagnostic code, the evidence must show occasional involuntary bowel movements necessitating the use of a pad. See Id. Here, the Board determines that a rating in excess of 10 percent is not warranted for any period on appeal. Specifically, at VA examinations in October 2011, November 2015, and January 2017, while the Veteran reported a past history of bowel incontinence, there was no evidence that the Veteran was currently experiencing incontinence, involuntary bowel movements, or used pads. Moreover, the examiners all indicated that the Veteran did not have any bowel disturbances. Next, while the Veteran's treatment records report the Veteran's assertions that he had occasional involuntary bowel movements, there is no evidence that he needed to use pads. Specifically, the treatment records from December 2012, October 2013, June 2015, and October 2016 all note the Veteran's occasional incontinence, but do not indicate the Veteran needed pads or other appliances. Therefore, a rating in excess of 10 percent is not warranted. Left Inguinal Hernia The Veteran's service-connected left inguinal hernia has been assigned a noncompensable rating under 38 C.F.R. § 4.111, DC 7338. In order to warrant a compensable rating, the evidence must demonstrate a postoperative recurrent inguinal hernia, readily reducible, and well supported by truss or belt (10 percent), or a small inguinal hernia, postoperative recurrent, or unoperated irremediable, not well supported by truss, or not readily reducible (30 percent). See Id. In this case, the Board determines that a compensable rating is not warranted for any period on appeal. Specifically, in an October 2011 VA examination, the examiner noted that the Veteran's left inguinal hernia was never surgically repaired. Further, while the Veteran experienced pain from the hernia, there was no evidence that he needed to use a supporting belt. Moreover, in a November 2015 VA examination, there was no indication that the Veteran had an inguinal hernia. Additionally, the Veteran's treatment records do not indicate that a higher rating is warranted. Of note, the Veteran's October 2011 treatment records did not reveal evidence of a hernia. Moreover, there is no indication in the records that the Veteran's hernia required surgery or the use of a belt or truss. As a result, a compensable rating is not warranted. Left Finger Disorder The Veteran is currently service-connected for an injury to the left fifth metacarpal with a noncompensable rating under 38 C.F.R. § 4.71a, DC 5230 (addressing limitation of motion of the small finger). There are a number of diagnostic codes that are potentially applicable under 38 C.F.R. § 4.71a. Specifically, DC 5227 is for application when there is ankylosis of either the fourth or fifth finger and DC 5230 is for application where there is limitation of motion in the fourth or fifth finger. A compensable rating is not available, regardless of the type of ankylosis or how severe the limitation may be. Moreover, although VA must generally consider "functional loss" of a musculoskeletal disability separately from consideration under the diagnostic codes, the applicable rating criteria here do not provide for a disability rating in excess of noncompensable for loss of range of motion. Additionally, when increased ratings are not reliant on limitation of motion symptomatology, it is not necessary to consider whether 38 C.F.R. § 4.40 and 4.45 are applicable. See DeLuca, 8 Vet. App. at 202; Johnston, 10 Vet. App. at 85. Therefore, a compensable rating is not for application under these diagnostic codes. The Board has considered assigning a separate rating under DCs 5228 and 5229, for limitation of motion in the thumb and index finger, respectively; however, there is no evidence that the Veteran has any service-connected condition or diagnosis affecting these fingers. Consideration has also been given to DC 5156, which allows for a 10 percent rating when there is an amputation without metacarpal resection. However, the assignment of an analogous rating would be inappropriate in the present case. Notably, VA examinations in October 2011 and November 2015 indicate that the Veteran retained active motion in all fingers of the left hand. Based on such evidence, it is clear that Veteran derives greater function from his finger than if the finger was amputated. Therefore, given that there is no diagnostic code that allows for a compensable evaluation for non-amputation injuries to the fifth finger of the left hand, a compensable rating is not warranted. In considering the appropriate disability rating, the Board has also considered the statements from the Veteran that his service-connected disabilities are worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his service-connected disorders according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). On the other hand, such competent evidence concerning the nature and extent of the Veteran's disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Specifically, with respect to his psychiatric disorder, while the Veteran reported that he had impulse control problems, suicidal ideations, and panic attacks, these symptoms were discussed and addressed by the VA examiners and treating medical providers. The Board also finds that consideration for an extraschedular evaluation, a component of a claim for an increased rating, is not warranted. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). As such, the Veteran's symptoms are not which are so unusual that they are outside the schedular criteria. In considering whether an extraschedular rating may be warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. See Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the Board has reviewed all of his relevant symptoms related to the issues on appeal, including limitations with activities of daily living, and concludes that there are no symptoms that were not able to be addressed by the applicable diagnostic codes. See Mittleider v. West, 11 Vet. App. 181 (1998). Moreover, as was established in Mauerhan, 16 Vet. App. at 444, a schedular rating for psychiatric disorders is not necessarily limited to the enumerated symptoms in the general rating formula, and no relevant symptoms have been excluded in the Board's analysis. As such, the Veteran's symptoms are not which are so unusual that they are outside the schedular criteria. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). TDIU The Veteran has asserted that he has been unable to work because of his service-connected disabilities. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). A total disability rating for compensation purposes may be assigned on the basis of "individual unemployability," or 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. 38 C.F.R. § 4.16(a). In such an instance, if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. The Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected conditions and advancing age, which would justify TDIU. 38 C.F.R. §§ 3.341(a), 4.19; See Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). In this case, the Board determines that TDIU should be granted. As an initial matter, the Board notes that the Veteran meets the schedular requirements for TDIU throughout the period on appeal. The Veteran is service-connected for the following: psychiatric disorder (50 percent), sleep apnea (50 percent); back disorder (20 percent prior to May 27, 2009, 40 percent prior to January 12, 2017, and 20 percent thereafter), bowel incontinence (10 percent), bilateral lower radiculopathy (two separate 10 percent ratings), right knee disorder (10 percent), tinnitus (10 percent as of December 25, 2015), and noncompensable ratings for a left finger disorder, hernia, headaches, and erectile dysfunction. Therefore, the Veteran has an overall combined disability rating of 80 percent prior to May 27, 2009, and 90 percent thereafter. Further, the evidence demonstrates that while the Veteran was working part-time as late as 2016, he has been unable to obtain gainful employment since that time. In making this determination, the Board places significant probative value on the private opinions from his the Veteran's psychiatrist, as well as the Veteran's contentions that the combined effects of his service-connected disabilities, including his psychiatric and back disorders prevented him from working. Specifically, the Board acknowledges the Veteran's credible and competent statements which reflect that his service-connected disabilities forced him to quit his job working for an auto-parts store, given that he could no longer perform his job duties, which required significant concentration, physical activity, and the ability to work with other people. Moreover, the Board also places significant probative value on the opinions from the VA examiners which indicate that the Veteran's service-connected disabilities caused significant interference with his ability to work. Again, the question in this case is whether the Veteran could secure or follow substantially gainful employment, not whether he was totally precluded from work. The evidence in this case places the question of substantially gainful employment in great doubt, and the Board has resolved all doubt in the Veteran's favor. Accordingly, entitlement to TDIU is granted. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). VA Duty to Notify and Assist The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA), which includes an enhanced duty on the part of VA to notify a veteran of the information and evidence necessary to substantiate claims for VA benefits. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). The VCAA also redefines the obligations of VA with respect to its statutory duty to assist veterans in the development of their claims. 38 U.S.C. §§ 5103, 5103A. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C. § 5103(a) (2012); 38 C.F.R. § 3.159(b) (2017); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran was provided notice letters informing him of both his and VA's obligations. Moreover, there is no indication of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Therefore, additional notice is not required and any defect in notice is not prejudicial. With respect to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). The Board finds that all necessary assistance has been provided to the Veteran. Indeed, all VA treatment records and relevant private treatment records have been obtained. The Veteran has also been provided with VA examinations. Upon review of these examination reports, the Board observes that the examiners reviewed the Veteran's past medical history, recorded his current complaints and history, conducted appropriate evaluations and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The VA examination reports are therefore adequate for the purpose of rendering a decision on appeal. 38 C.F.R. § 4.2 (2017); Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, no further notice or assistance is required to fulfill VA's duty to assist in the development of the above-cited claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER A rating in excess of 50 percent for an acquired psychiatric disorder, characterized as a depressive disorder, is denied. An initial compensable rating for a headache disorder is denied. A rating in excess of 10 percent for a bowel disorder is denied. A compensable rating for a left inguinal hernia is denied. A compensable rating for residuals of an injury to the fifth metacarpal on the left hand is denied. TDIU is granted. ____________________________________________ B.T. KNOPE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs