Citation Nr: 21064106 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 17-40 046 DATE: October 19, 2021 ORDER Entitlement to service connection for lumbar spine disability is denied. Entitlement to service connection for radiculopathy, right lower extremity, is denied. Entitlement to service connection for radiculopathy, left lower extremity, is denied. Entitlement to service connection for hypertension, including secondary to posttraumatic stress disorder (PTSD), is denied. Entitlement to an initial evaluation in excess of 50 percent for PTSD, prior to February 11, 2020, is denied. Entitlement to an evaluation in excess of 70 percent for PTSD, since February 11, 2020, is denied. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU), prior to February 11, 2020, is denied. FINDINGS OF FACT 1. The Veteran's lumbar spine disability, diagnosed as lumbosacral strain, degenerative arthritis of the spine, and intervertebral disc syndrome, status post multiple surgeries, were not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The Veteran's radiculopathy, right lower extremity, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 3. The Veteran's radiculopathy, left lower extremity, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 4. The Veteran's hypertension was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not secondary to any service-connected disability, and is not otherwise related to an in-service injury or disease. 5. Prior to February 11, 2020, the Veteran's PTSD symptoms were productive of occupational and social impairment with reduced reliability and productivity; and the severity, frequency, and duration of the Veteran's PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 6. Since February 11, 2020, the Veteran's PTSD symptoms were productive of occupational and social impairment with deficiencies in most areas; and the severity, frequency, and duration of the Veteran's PTSD symptoms did not more closely approximate total occupational and social impairment at any point during this appeal. 7. Prior to February 11, 2020, service connection had only been established for PTSD, which was evaluated as 50 percent disabling; the evidence does not show that this single disability resulted in an inability to secure or follow a substantially gainful occupation. 8. Prior to February 11, 2020, the Veteran was not precluded from obtaining and securing substantially gainful employment as a result of her service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for lumbar spine disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for radiculopathy, right lower extremity, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for radiculopathy, left lower extremity, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for entitlement to service connection for hypertension, including secondary to PTSD, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 5. The criteria for an initial evaluation in excess of 50 percent for PTSD, prior to February 11, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 6. The criteria for an evaluation in excess of 70 percent for PTSD, since February 11, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 7. The criteria for entitlement to a TDIU, prior to February 11, 2020, have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. § §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from January 1991 to July 1991, and on active duty for training from May 1988 to September 1988 and August 1991 to January 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2014, June 2017, and August 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran testified at a video conference hearing held before the undersigned Veterans Law Judge. A transcript of this hearing has been added to the record. In June 2020, the Board remanded this matter for additional evidentiary development. The RO subsequently obtained relevant treatment records identified by the Veteran, along with other pertinent records from the Social Security Administration (SSA). The Board finds these actions to be in substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that substantial, rather than strict, compliance with remand directives is required). In February 2021, the RO issued a rating decision which granted an increased evaluation of 70 percent for PTSD, effective February 11, 2020; and also granted entitlement to a TDIU, effective February 11, 2020. For the sake of clarity, the Board has restated the evaluation of PTSD issue to reflect the currently assigned staged ratings. Moreover, although the RO granted entitlement to a TDIU, effective February 11, 2020, the issue of entitlement to a TDIU, prior to February 11, 2020, remains in appellate status. Payne v. Wilkie, 31 Vet. App. 373 (2019); Harper v. Wilkie, 30 Vet. App. 356 (2018). Service Connection Service connection may be established 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. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed.Cir.2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Moreover, where a veteran served continuously for 90 days or more during active service, and arthritis, hypertension, and other/or other organic diseases of the nervous system manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability that is aggravated by a service-connected disability may be service connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for lumbar spine disability. 2. Entitlement to service connection for radiculopathy, right lower extremity. 3. Entitlement to service connection for radiculopathy, left lower extremity. The Veteran contends that her lumbar spine disability and radiculopathy of the lower extremities began during her active service. The Veteran has a current lumbar spine disability, including diagnoses of lumbosacral strain, degenerative arthritis of the spine, intervertebral disc syndrome, and radiculopathy of the lower extremities, status post multiple surgeries. Arthritis and radiculopathy are enumerated conditions under 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed.Cir. 2013). A review of the Veteran's service treatment records reveals that she was seen in March 1991 for right lower back pain for the past 30 days due to working in a strained position while using a dental assistant's chair. A March 1991 consultation report listed a provisional diagnosis of acute myofascitis lumbar spine with right sciatica. A May 1992 physical examination listed the Veteran's spine and lower extremities as normal. On a medical history report, completed at that time, the Veteran indicated that she has had no recurrence of back pain since July 1991. A July 1993 neurological evaluation revealed motor strength of 5/5 in all of the Veteran's extremities, and that her reflexes were 2+ and symmetrical without delayed relaxation phase. Through statements and testimony, the Veteran has claimed that her lumbar spine disability and radiculopathy of the lower extremities continued to bother her ever since her in-service back injury. The first post service evidence of record relating to the Veteran's lumbar spine disability and/or radiculopathy of the lower extremities was in November 2004. Specifically, a November 2004 private treatment report noted the Veteran's complaints of back pain. In June 2005, the Veteran filed a claim seeking SSA disability benefits. At that time, the Veteran claimed she was disabled and unemployed due to a crushed left foot, diabetes mellitus, and hyperthyroidism. No reference was made as to any lumbar spine disability and/or radiculopathy of the lower extremities. On her SSA application, the Veteran reported a ten-year history of performing physically demanding work as a registered nurse, including lifting 100 or more pounds, as well as frequently lifting 25 pounds. A September 2005 private treatment report noted the Veteran's history of a crushed left foot, diabetes mellitus, weight gain, and urinary tract infection. At that time, she denied having any numbness, tingling, or swelling in her hands or feet. Physical examination listed her spine as normal. No reference was made to any ongoing back problems, back injury, and/or radiculopathy of the lower extremities. A January 2006 private treatment report noted the Veteran's history of a broken foot, hip pain, and diabetes mellitus. No reference was made to any ongoing back problems, back injury, and/or radiculopathy of the lower extremities. A March 2006 private treatment report noted that the Veteran's medical history of multiple conditions. No reference was made to any ongoing back problems, back injury, and/or radiculopathy of the lower extremities. Initially, the Board finds that service connection for a lumbar spine disability and/or radiculopathy of the lower extremities is not warranted on a presumptive basis. Although her service treatment records document an in-service lumbar spine injury with right sciatica, a chronic disability is not shown. No significant follow up treatment or complaints of a lumbar spine disability and/or radiculopathy of the lower extremities were shown. The Veteran's May 1992 physical examination listed her spine and lower extremities as normal. On a medical history report, completed at that time, the Veteran denied any recurrence of back pain since July 1991. Finally, no post service complaints of or treatment for lumbar spine disability or radiculopathy of the lower extremities were shown until November 2004, a decade outside of the applicable presumptive period. Based upon a longitudinal review of the evidence of record, the Board concludes that the preponderance of the evidence is against finding that a medical nexus exists between the Veteran's current lumbar spine disability and radiculopathy of the lower extremities and any in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. Thus, service connection for a lumbar spine disability and/or radiculopathy of the right and left lower extremities on a direct basis must also be denied. While the Veteran is competent to report having experienced ongoing symptoms of back pain since service, the Board finds her contentions of continuity of symptomatology to be lacking in credibility. The Veteran's contentions are internally inconsistent with the history reports in contemporaneous treatment records. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). No follow up treatment or ongoing complaints of back pain are noted in the Veteran's subsequent service treatment records. The Veteran's May 1992 physical examination listed her spine and lower extremities were normal. On a medical history report, completed at that time, she denied any recurrence of back pain since July 1991. Thereafter, the record is silent as to any complaints of a lumbar spine disability and radiculopathy of the lower extremities, including an absence of these disabilities in multiple medical histories taken in 2005 and 2006, including Veteran's SSA disability claim filed in June 2005. The Veteran in this case is also not competent to provide a nexus opinion regarding these issues. The issues are medically complex, as it requires knowledge of anatomical relationships and pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to competent medical evidence of record. The April 2017 VA examiner opined that that the Veteran's current lumbar spine disability and radiculopathy of the lower extremities were less likely than not incurred in or caused by her military service. In support of this opinion, the VA examiner noted that there was no chronicity to the single episode of back pain and right sciatica experienced by the Veteran in service. The VA examiner noted that the lack of continuity of care, treatment, or complaints since service makes it less likely than not that the Veteran's current disability is related to her military service. The Board finds this opinion to be both adequate and probative as to the questions at issue, as the examiner reviewed the Veteran's claims file, made specific references to the record, and provided a well-reasoned rationale. Accordingly, the preponderance of the evidence is against the Veteran's claims for service connection for lumbar spine disability and radiculopathy of the lower extremities. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for hypertension, including secondary to PTSD. The Veteran contends that she developed hypertension as a result of her military service. Alternatively, she contends that her hypertension was caused or aggravated by her service-connected PTSD and/or her lumbar spine disability. The Veteran has a current diagnosis of hypertension as evidenced by her February 2021 VA examination for hypertension. Hypertension is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. The Veteran's service treatment records are silent as to any treatment for or diagnosis of hypertension. The Veteran's May 1992 physical examination noted that her heart and vascular system were normal. On a medical history report, completed at that time, the Veteran denied having a history of high blood pressure. Post service treatment reports, dated in August 1993 and October 1993, recorded blood pressure readings of 100/70 and 110/80, respectively. The first post service treatment report noting a diagnosis of hypertension was in March 2006, over 14 years after the Veteran's separation from active service, and over a decade outside of the applicable presumptive period. The Veteran has also not claimed or reported having ongoing symptomatology relating to hypertension since her discharge from the service. Thus, no evidence of continuity of symptomatology is shown. The remaining question for the Board is whether the Veteran's hypertension is proximately due to or the result of, or was aggravated beyond its natural progress by a service-connected disability. The Board concludes that, while the Veteran currently has hypertension, the preponderance of the evidence is against finding that the Veteran's hypertension is proximately due to or the result of, or aggravated beyond its natural progression by her service-connected PTSD. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The February 2021 VA examiner opined that the Veteran's hypertension is less likely as not caused or aggravated by her service-connected PTSD. In support of this opinion, the VA examiner noted that while blood pressure can temporarily be affected by other conditions such as pain and mental stressors, hypertension does go back down to its baseline. The VA examiner noted that the Veteran has a history of nonservice-connected diabetes mellitus which is directly linked to her hypertension. The VA examiner also noted that the Veteran's body mass index is in the overweight category. As before, the Board finds this opinion to be adequate for rating purposes, as it contains specific references to the Veteran's medical history, considered her statements, and contains a well-reasoned rationale supporting its conclusions. The Veteran believes her hypertension is proximately due to or aggravated beyond its natural progression by her service-connected PTSD, but she is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The Veteran is not currently service-connected for any lumbar spine or lower extremity disabilities. Accordingly, the Veteran's hypertension cannot be established on a secondary basis to these disabilities. Consequently, the Board gives more probative weight to the February 2021 VA examiner's opinion, as well as the Veteran's service and post service treatment records, which are silent as to any treatment for or diagnosis of hypertension during service, or for more than a decade thereafter. Therefore, service connection for hypertension must be denied. 5. Entitlement to an initial evaluation in excess of 50 percent for PTSD, prior to February 11, 2020. The Veteran contends that prior to February 11, 2020, her service-connected PTSD warrants an evaluation in excess of 50 percent. Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by replacing references to DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV) with the fifth edition of the DSM (DSM-5). See 38 C.F.R. § 4.125, amended by 79 Fed. Reg. 45099 (effective Aug. 4, 2014). As the appeal was certified to the Board after this change, DSM-5 applies. See 80 Fed. Reg. 14, 308 (March 19, 2015). Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's PTSD associated symptoms caused the level of impairment required for an initial evaluation of 70 percent or higher at any point prior to February 11, 2020. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher at any point prior to February 11, 2020. The Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. In this case, the Veteran's VA medical records show that prior to February 11, 2020, she has suffered from anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. In March 2017, the Veteran underwent a VA examination for PTSD. The VA examiner noted that the Veteran's claims file had been reviewed and a mental status examination of the Veteran conducted. The Veteran reported that she has been married for the past two years, and that she was living with her husband and two children. She described moderate socialization and interpersonal interactions, with some isolation and alienation at times. She indicated that she has been employed as a registered nurse at the same location for the past six months, and at a prior location for three years prior to that. The Veteran was described as euthymic with an appropriate range in affect; alert and oriented; no disturbances in speech, thought, memory, concentration, or behavior. Her insight and intelligence were good. The VA examiner noted PTSD symptoms including anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. Overall, the VA examiner concluded that the Veteran's PTSD symptoms result in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Board finds the severity, frequency, and duration of the Veteran's PTSD symptoms are no worse than the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. Accordingly, the preponderance of the evidence is against the Veteran's claim for an evaluation in excess of 50 percent for her PTSD prior to February 11, 2020. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the preponderance of the evidence is against an initial evaluation in excess of 50 percent for her PTSD at any time prior to February 11, 2020. 6. Entitlement to an evaluation in excess of 70 percent for PTSD, since February 11, 2020. Since February 11, 2020, the RO has assigned the Veteran's PTSD an evaluation of 70 percent pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the governing regulatory rating criteria, PTSD is rated under a "General Rating Formula for Mental Disorders". 38 C.F.R. § 4.130, Diagnostic Code 9411. Under this Formula, a 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. After a careful review of all the evidence of record, lay and medical, the Board finds that the Veteran's PTSD has not been productive of total social and occupational impairment at any point since February 11, 2020. A February 2020 private psychiatric evaluation noted the Veteran's PTSD symptoms including depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, circumstantial, circumlocutory, or stereotyped speech, impaired judgment, disturbances of motivation and mood, difficulty in stablishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, suicidal ideation, and impaired impulse control. The private physician concluded that overall the Veteran's occupational and social impairment can best be summarized as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The Veteran's most recent VA examination for PTSD, conducted in June 2020, noted that she lived at her home with her husband, her son and step son. She was not currently working, and has very little social contact outside of her immediate family in the home. The report noted PTSD symptoms including depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss, and difficulty in adapting to stressful circumstances. The examiner noted that the Veteran exhibited a mildly constricted affect. She shed some tears during the examination, but was able to regain her composure. She was pleasant and cooperative throughout. The VA examiner concluded that overall the Veteran's occupational and social impairment can best be summarized as occupational and social impairment with reduced reliability and productivity. In sum, the evidence does not reflect symptomatology resulting in total occupational and social impairment. Accordingly, the preponderance of the evidence is against assigning a disability rating in excess of 70 percent for PTSD at any point since February 11, 2011, and the doctrine of reasonable doubt is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-57. 7. Entitlement to a TDIU, prior to February 11, 2020. VA will grant TDIU when the evidence shows that a veteran is precluded by reason of a service-connected disability or disabilities from obtaining and maintaining substantially gainful employment consistent with her education and occupational experience. 38 C.F.R. § §§ 3.340, 3.341, 4.16. Advancing age, any impairment caused by conditions that are not service connected, and prior unemployability status must be disregarded when determining whether a Veteran is currently unemployable. 38 C.F.R. § §§ 4.16(a), 4.19. A total disability rating may be assigned when the schedular rating is less than total, where, if there is only one disability, the disability is rated at 60 percent or more, or where, if there are two or more disabilities, at least one disability is rated 40 percent or more and there is sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § § 4.16(a). Where the percentage requirements for TDIU are not met, a total disability rating may nevertheless be assigned on an extraschedular basis when the veteran is unable to secure or follow a substantially gainful occupation as a result of her or her service-connected disability or disabilities. 38 C.F.R. § § 4.16(b). The Board is precluded from assigning a TDIU rating on an extraschedular basis in the first instance. Instead, a claim that meets the criteria for referral for consideration of entitlement to a TDIU rating on an extraschedular basis must be referred to the Director of Compensation Service for consideration. See Bowling v. Principi, 15 Vet. App. 1, 10 (2001). For a veteran to prevail on a claim for a TDIU rating, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. See 38 C.F.R. § 4.16(a). Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Veteran's claim for a TDIU arises from her claims filed in December 2012. Prior to February 11, 2020, the Veteran was service connected for PTSD, evaluated as 50 percent disabling. As an initial matter, it is noted the Veteran's disability percentage prior to February 11, 2020, does not meet the minimum schedular requirements for a TDIU under 38 C.F.R. § 4.16(a), and a schedular TDIU, cannot be granted for any point throughout the appeal period. While the Veteran could theoretically still qualify for an extraschedular TDIU, referral for extraschedular consideration is not warranted, as unemployability due to her service-connected PTSD is not shown in the competent evidence. Based upon a longitudinal review of the record, the Board concludes that the evidence does not show that the Veteran had been rendered unemployable by reason of her service-connected PTSD at any point prior to February 11, 2020. On her TDIU application, filed in May 2020, the Veteran indicated that she was last employed as a registered nurse in June 2017. On her application for SSA disability benefits, filed in September 2017, the Veteran indicated that she had been steadily employed as a registered nurse from March 2012 until June 2017. On her SSA disability claim form, the Veteran reported that she was seeking disability benefits due to her PTSD, as well as degenerative disc disease, inability to stand/sit for long periods, osteoarthritis in both hips, lumbar spine disability, osteoarthritis in both knees, cervical spine bulging/herniated disc, high blood pressure, and diabetes mellitus. The March 2017 VA examination for PTSD noted symptoms including anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. Overall, the VA examiner concluded that the Veteran's PTSD symptoms result in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The report noted that the Veteran had been working as a registered nurse for the past six months at a veterans' care facility, and that she was employed as an emergency room nurse for three years prior to her current employment. While the Veteran discontinued her employment in June 2017, a review of the evidence of record does not suggest that she was precluded from obtaining and securing substantially gainful employment as a result of his service-connected PTSD at any time during the period on appeal. For these reasons, the Board finds that the weight of the evidence demonstrates that the criteria for TDIU rating have not been met at any point throughout the appeal period. As unemployability due to service-connected disability is not shown, referral for an extraschedular TDIU is also not warranted. The weight of the evidence is against the claim, and the provisions of 38 C.F.R. § 3.102 are not applicable. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board W. Yates, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.