Citation Nr: 21021731 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 15-09 806 DATE: April 13, 2021 ORDER A rating in excess of 50 percent for a generalized anxiety disorder since November 12, 2010 is denied. Service connection for posttraumatic stress disorder (PTSD) and/or depression as secondary to service-connected generalized anxiety disorder (GAD) is denied. A total disability rating based in individual unemployability due to service-connected disabilities (TDIU) since November 12, 2010 is denied. FINDINGS OF FACT 1. Since November 12, 2010, the Veteran’s generalized anxiety disorder (GAD) manifested as occupational and social occupational with reduced reliability and productivity due to such symptoms as panic attacks; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 2. There is no probative medical evidence that indicates the Veteran has PTSD. 3. There is no probative medical evidence that indicates the Veteran demonstrates additional depressive symptoms not already compensated under his current service-connected GAD. 4. The Veteran’s physical and mental impairments caused by his service-connected disabilities do not render him unable to obtain or maintain gainful employment. CONCLUSIONS OF LAW 1. Since November 12, 2010, the criteria for a disability rating in excess of 50 percent for generalized anxiety disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.14, 4.130, Diagnostic Code (DC) 9400 (2019). 2. The criteria to establish service connection for PTSD and depression have not been satisfied. 38 U.S.C. §§ 1110, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2019). 3. Since November 12, 2010, the criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.10, 4.16, 4.18, 4.19, 4.25 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1970 to September 1971. During the pendency of the appeal, a September 2020 rating decision granted the Veteran a 30 percent evaluation since August 1, 1979, for his service-connected schizophrenia disability, thus reinstating the Veteran’s previously reduced evaluation. The Veteran’s claim for an earlier effective date for his service-connected schizophrenia evaluation is no longer in appeal status. In addition, the September 2020 rating decision increased the Veteran’s acquired psychiatric disability rating to 50 percent effective November 12, 2010, the date of the Veteran’s claim for an increased rating. Since this evaluation is not the maximum available benefit and the claimant has not withdrawn the appeal, the issue remains in appeal status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (where a claimant has filed a NOD as to an RO decision assigning a rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). Thus the issue on appeal is as listed in the decision. The issue of a total disability rating based on individual unemployability (TDIU) has been raised under Rice v. Shinseki, 22 Vet. App. 447 (2009) and is associated with the underlying increased rating claim. The appellate period is as listed in the decision. The case was remanded in September 2018 for development and for a new medical examination and opinion. All actions ordered by the remand have been accomplished. Increased Ratings Disability ratings are determined by applying criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). Additionally, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In assigning a higher disability rating, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Mental Disorders The General Rating Formula for mental disorders is as follows: A 100 percent rating is assigned for 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. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 50 percent rating is assigned for 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. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130 (2019). The symptoms associated with each rating in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list; rather, they serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the DCs. See Id. VA must consider all symptoms of a claimant’s disorder that affect his or her occupational and social impairment. See Id. at 443. If the evidence demonstrates that a claimant has symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the DC, the appropriate, equivalent rating will be assigned. Id. In this regard, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126. Although VA considers the level of social impairment, it does not assign an evaluation based solely on social impairment. Id. VA must consider all of the claimant’s symptoms and resulting functional impairment as shown by the evidence in assigning the appropriate rating and will not rely solely on the examiner’s assessment of the level of disability at the moment of examination. See Id.; see also Vazquez–Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). 1. Entitlement to a rating in excess of 50 percent from since November 12, 2010, for GAD The Veteran’s service-connected acquired psychiatric disorder disability has been evaluated as 50 percent disabling since November 12, 2010, under the schedule of ratings for mental disorders. See 38 C.F.R. § 4.130, DC 9201. The Veteran’s original psychiatric disorder disability was schizophrenia with paranoid psychosis and was rated under diagnostic code 9203. Legislative changes to the diagnostic code in 2014 removed this DC. The Veteran’s current service-connected acquired psychiatric disorder diagnosis is generalized anxiety disorder (GAD). In an October 2010 VA treatment record, the Veteran reported treatment for schizophrenia and anxiety; endorsed PTSD symptoms of nightmares, flashbacks, and auditory hallucination for the prior month; and also endorsed mild depression. The Veteran denied current PTSD symptoms, reported being anxious “all his life” with obsessive ruminating thoughts, and endorsed having a supportive family. The examiner conducted a psychiatric interview, noted prior psychotropic medication regimen for paranoid schizophrenia, and noted the Veteran denied neurovegetative signs of depression. The examiner diagnosed the Veteran with generalized anxiety disorder (GAD) / obsessive compulsive disorder (OCD). The examiner started the Veteran on Celexa, an anti-depressant. December 2010 VA treatment records indicate the Veteran reported anxiety, and feeling uncomfortable in social situations. He also reported good sleeping and appetite habits. A mental status examination revealed neutral or stable mood; distractible attention; impaired concentration; and otherwise normal or adequate responses. The examiner noted the Veteran denied suicidal ideation, medication side effects, and psychotic symptoms. The examiner diagnosed the Veteran with GAD / OCD, and noted the Veteran’ schizophrenia was service connected. At the March 2011 VA medical examination, the examiner noted that the October 2010 treatment summary indicated the Veteran endorsed PTSD symptoms and not that the Veteran had a current diagnosis of PTSD. The Veteran reported symptoms of anxiety, anger, marital and familial conflict, obsessive thoughts, auditory hallucinations, sleep interference, and irritability. The examiner diagnosed the Veteran with psychotic disorder not otherwise specified (NOS), noted that the diagnosis was a continuation of the Veteran’s service-connected paranoid schizophrenia, but that the Veteran did not report symptoms consistent with any other psychiatric disorders, to include PTSD and depression. The examiner noted the psychotic disorder NOS symptoms required continuous medication which the Veteran reported helped him sleep and reduce his levels of anxiety and anger. The examiner reiterated that the Veteran’s treating VA psychiatrist did not diagnose the Veteran with PTSD. The examiner noted that the Veteran’s reported experiences of fear of hostile military or terrorist activity during his Vietnam service were not adequate to support a diagnosis of PTSD. Subsequent 2011 VA treatment records indicate the Veteran reported “residual” PTSD symptoms of nightmares, flashbacks, and auditory hallucinations; anxiety over his realty business and other financial concerns; improved sleep with medication; and denied hopelessness, suicidal ideation, and alcohol and drug abuse. Mental status examinations generally revealed distractible attention, impaired concentration, and otherwise normal or adequate responses. The Veteran’s treating examiner continued to note the Veteran’s diagnoses as GAD / OCD. VA treatment records for 2012 indicate the Veteran reported reduced nightmares and flashbacks with occasional disturbed sleep; continued anxiety over his real estate business and other financial issues; and denied hopelessness, suicidal ideation, and alcohol or drug abuse, or psychotic symptoms. His treating examiner continued to note the Veteran’s diagnoses as GAD / OCD. In June 2012 the Veteran requested individual therapeutic sessions. In December 2012 the Veteran reported “worrying obsessively” about his financial situation. In January 2013 the Veteran began individual psychotherapy sessions. The examiner and his attending student conducted a lengthy interview. A mental status evaluation indicated the Veteran demonstrated good hygiene, normal speech, good orientation, logical thinking, with psychomotor agitation. He denied suicidal ideation, current and past auditory or visual hallucinations, and delusions. The examiners noted that the Veteran demonstrated GAD, with an obsessive nature that did not warrant a separate OCD diagnosis; rule/out major depressive disorder without anhedonia or recurrent thoughts of death; rule/out dysthymic disorder; rule/out bipolar disorder; and rule/out cyclothymic disorder. The examiners noted that the Veteran did not demonstrate or endorse symptoms warranting a schizophrenia diagnosis but that the Veteran’s depressive symptoms were causing clinically significant distress. In a private March 2013 psychological evaluation, Dr. J. Rubin reviewed the Veteran’s December 2003 and October 2010 VA medical progress notes and conducted a clinical interview. Dr. Rubin noted that previous psychiatric records indicated the Veteran was diagnosed with anxiety disorder not otherwise specified (NOS) in October 2010. The Veteran reported low motivation; low energy; vegetatively depressed moods; loss of interest and pleasure; irrational anger outbursts; and a history of severe anxiety during service where he was assigned to guard and supply ammunitions depots that were attacked or that would inexplicably explode. The examiner noted the Veteran’s responses were consistent with considerable anxiety, clinically significant depression, but with no evidence of hallucinations, delusions, or other underlying psychopathology. The examiner noted the Veteran endorsed general nervousness; tension; anxiety/fear; excessively watchful and overly cautious; bad or troubling dreams or nightmares; sleep disturbance; sexual problems; feeling weak and fatigued; headaches and dizziness; concentration problems; forgetfulness; irritability and impatience, including with others; withdrawal and isolative behavior; family problems and friction; changes in level of work performance sad or depressed mood, with crying spells; sensitivity to noise; recurrent thoughts or rumination; avoidance; flashbacks of traumatic situations; increased distractibility; panic attacks; frightening thoughts and images; anger or irritability; loss of interest or pleasure in usual activities; feeling apathetic or little motivation. The examiner opined the Veteran’s responses were consistent with the types of emotional reactions clinically indicative of depressive, anxiety and schizophrenic disorders. The examiner diagnosed the Veteran with generalized anxiety disorder; dysthymic disorder; and schizophrenia, paranoid (under control). The examiner noted the Veteran’s symptoms resulted in moderate social and occupational functional impairment. The examiner later stated that the Veteran’s psychological disability was moderately to markedly impairing and likely to be permanent. He further opined that any engagement in employment was likely to result in an acute deterioration in his psychiatric functioning. Subsequent VA treatment records for 2013 indicate the Veteran reported increased tension and anxiety due to health, financial, marital, and other familial concerns. He endorsed good sleep and appetite patterns, and denied depression, hopelessness, suicidal ideation, alcohol, and drug abuse. His mental status evaluations generally indicated appropriate or normal responses. His treating psychologist diagnosed him with GAD; substance abuse in full remission; and major depressive disorder (MDD). In May 2013 the Veteran ended his individual psychiatric therapy and began supplemental psychoeducational group therapy. For the remainder of 2013, the Veteran received periodic medication management followup consultations. He generally endorsed anxiety; denied depression or hopelessness, suicidal ideation, and alcohol and drug abuse; and reported good sleeping and appetite habits. His medication management examiner continued to diagnose the Veteran with GAD / OCD. VA treatment records for 2014 indicate the Veteran reported a stable mood but increased anxiety and depression due to familial concerns and his upcoming hernia surgery. The Veteran continued to deny hopelessness, suicidal ideation, and alcohol and drug abuse. He also reported improvement in symptomatology in part due to attending multiple group sessions such as music reminiscence and humor group. The Veteran’s medication management examiner continued to diagnose the Veteran with GAD / OCD. VA treatment records for 2015 indicate the Veteran denied depression due in part to resolution of some familial issues. He also denied suicidal ideation and alcohol and drug abuse. His medication management examiner continued his medication regimen and continued his diagnoses as GAD / OCD. In a private October 2015 psychological evaluation, Dr. Balada diagnosed the Veteran with schizophrenia, paranoid type. She noted that the Veteran endorsed poor concentration; extreme fluctuations in mood; irritability; poor memory; and poor attention. She also noted the Veteran had not worked full time since 2011, and that he would be unable to perform competitive work duties due solely to his service-connected psychiatric impairments. VA treatment records for 2016 indicate the Veteran continued to endorse anxiety, and denied depression, suicidal ideation, and alcohol and drug abuse. His medication management examiner continued to diagnosis him with GAD / OCD. At the October 2017 VA medical examination, the examiner diagnosed the Veteran with GAD, and noted that this diagnosis was a continuation of the Veteran’s service-connected schizophrenia diagnosis that was previously diagnosed as psychotic disorder NOS at the March 2011 VA medical examination. The examiner also noted that the Veteran did not demonstrate any additional mental disorder diagnoses. The Veteran reported that his excessive anxiety, mood irritability, lack of patience, and difficulty interacting with people made it difficult for him to function as a real estate sales agent these past two years. He reported positive responses to continued medication, individual therapy in 2012-2013, as well as to subsequent group therapy sessions. The examiner noted the Veteran endorsed depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; and intermittent mild paranoia or auditory hallucinations. The examiner opined the Veteran’s psychiatric disorder demonstrated as occupational and social impairment with reduced reliability and productivity. At the April 2018 Board hearing, the Veteran reported he experienced lingering side effects from his psychotropic medication to include headaches and disorientation. He also reported that his panic attacks, memory loss and lack of concentration made realty work difficult. He reiterated that the private 2015 evaluation continued to reflect his current personal struggles with maintaining employment as a real estate agent and that since the 2008 real estate downturn he had experienced increased anxiety. At the November 2019 VA medical examination for mental disorders, the examiner diagnosed the Veteran with GAD, and a concussion from a 2007 motor vehicle accident (MVA). The examiner opined the Veteran’s psychiatric disorder resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occasional tasks only during periods of significant stress. The examiner reviewed the Veteran’s employment history, noting that in 2007 the Veteran had worked for over 30 years, but that in the past several years the Veteran reported increased anxiety due to financial concerns. The Veteran currently indicated he was retired. The examiner noted that since the Veteran’s 2017 VA medical examination, he continued to be prescribed anti-depressant and anti-anxiety medication. The examiner also reviewed the record for psychiatric analyses and diagnoses, and noted that psychiatric assessments of the Veteran as delusional were more likely manifestations of anxiety and not paranoid schizophrenia. The Veteran reported a history of depression in remission due to medication; a history of sleep impairment controlled by medication; and anxiety. The examiner also observed that the private 2015 examiner failed to provide a detailed report to support her conclusions that the Veteran demonstrated her diagnosis. The examiner noted the Veteran endorsed anxiety; chronic sleep impairment; and difficulty in establishing and maintaining effective work and social relationships. The examiner noted the Veteran’s mental status evaluation indicated normal or appropriate responses. In her opinion, the examiner noted that the Veteran’s responses were suggested of “feigning” but that based on the totality of the record and her interview, the Veteran warranted a diagnosis of generalized anxiety disorder only. She further noted that the GAD diagnosis was a continuation of his service-connected schizophrenia diagnosis. She noted she could not provide an opinion on whether any of the other diagnoses in the Veteran’s records were incurred in service because she explained that the private 2015 evaluation did not provide the needed support for the examiner’s diagnosis, and that VA treatment records consistently indicated that the Veteran’s psychiatric condition appeared to be anxiety-based. She further noted that with regards to social and occupational impairment, the Veteran could manage his funds in his own best interest; demonstrated mildly impaired ability to understand and follow instructions; demonstrated mildly impaired ability to retain instructions as well as sustained concentration to perform simple tasks; demonstrated mildly impaired ability to sustain concentration to task persistence and pace; demonstrated mildly impaired ability to respond to coworkers, supervisors, or the general public; and demonstrated mildly impaired ability to respond appropriately to changes in the work setting. Since November 12, 2010, the Veteran’s psychiatric disorder manifested as occupational and social occupational and social impairment with reduced reliability and productivity due to such symptoms as panic attacks; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships, and warrants a 50 percent rating. A higher rating is not warranted because the Veteran did not demonstrate symptoms such 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. The Board recognizes that the Veteran has an outstanding service connection claim for additional psychiatric diagnoses, which will be discussed below. At present, the Veteran’s service-connected mental disorder diagnosis is generalized anxiety disorder and is rated under DC 9400. Given these facts, the preponderance of the evidence is against the claim for an increased rating and the appeal will be denied. 38 C.F.R. § 4.7. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Since the Veteran does not allege direct service connection, nor does the record raise this theory of entitlement, the Board will restrict its analysis to secondary service connection only. Service connection for PTSD requires (1) a PTSD diagnosis conforming to the criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 4.125. In deciding an 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 favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination about the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran’s disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for PTSD and/or depression as secondary to service-connected mental disorders The Veteran contends he has PTSD and depression in addition to his service-connected schizophrenia diagnosis that warrant service connection. As noted, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). A review of the Veteran’s recent mental disorder treatments and diagnoses are noted above. The Veteran’s depressed mood and sleep impairment have both been evaluated and rated under his current service-connected GAD diagnosis. A review of the Veteran’s medical records does not indicate that he has a current diagnosis of PTSD. As noted at the March 2011 and November 2019 VA medical examinations, the Veteran’s reported symptoms did not meet the criteria for a clinical diagnosis of PTSD. Although the Veteran’s prior treating psychiatrist noted that the Veteran endorsed residual PTSD symptoms such as nightmares, flashbacks, and auditory hallucinations, the record does not indicate that the Veteran met the criteria for a clinical diagnosis of PTSD since service. With regards to depression, the last VA examiner to diagnose the Veteran with major depressive disorder did so in the context of possibly ruling it out as an active diagnosis. Since that time, although treatment records indicate the Veteran has reported subjective symptoms of depression on occasion, none of the Veteran’s treating psychiatrists or psychologists indicate that the Veteran has met the criteria for a clinical diagnosis of depression on a consistent basis. The Veteran does receive anti-depressant treatment in the context of addressing his sleep impairment symptoms; these symptoms are compensated under his service-connected GAD disability. Therefore, there is no probative medical evidence that indicates the Veteran has a separate depressive disorder that manifests with symptoms that are not already compensated under his service-connected GAD disability. As there is no probative medical evidence that indicates the Veteran has a current PTSD diagnosis, the claim for service connection is denied. Without a current disability, there can be no claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (“Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In absence of proof of a present disability there can be no valid claim.”). As there are is no probative medical evidence that indicates the Veteran demonstrates additional depressive symptoms not already compensated under his current service-connected psychiatric disorder, the claim for service connection for depression is also denied. TDIU A total rating based on unemployability due to service-connected disabilities may be granted if the service-connected disabilities preclude the Veteran from obtaining or maintaining substantially gainful employment consistent with his or her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16 (a). For those Veterans who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16 (a), total disability ratings for compensation may nevertheless be assigned when it is found that the service-connected disabilities are sufficient to produce unemployability; such cases should be referred to the Director, Compensation Service, for extraschedular consideration. 38 C.F.R. § 4.16 (b). Provision 38 C.F.R. § 4.16 (a) establishes that the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. In determining TDIU, the record must reflect some factor which takes the Veteran’s case outside the norm with respect to a similar level of disability under the rating schedule. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); 38 C.F.R. §§ 4.1, 4.15 (2016). The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether or not the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. Marginal employment shall not be considered substantially gainful employment, and generally shall be deemed to exist when a veteran’s earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16 (a). The central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to a veteran’s level of education, special training, and previous work experience, but advancing age and the impairment caused by nonservice-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose, 4 Vet. App. at 363. 3. Entitlement to TDIU since November 12, 2010 Service-connected disability compensation is in effect for GAD at 50 percent disabling; tinnitus as 10 percent disabling effective August 22, 2017; and noncompensable evaluations for erectile dysfunction and hearing loss. The combined rating for these disabilities is 50 percent effective November 12, 2010, and 60 percent effective August 22, 2017. The initial threshold requirements for entitlement to TDIU are thus not met during the appellate period. Because the ratings provided under the Schedule are averages, an assigned rating may be adequate to address the average impairment in earning capacity caused by the disability, but not completely account for the Veteran’s individual circumstances. Thun v. Peake, 22 Vet. App. 111, 114 (2008). The determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § or 4.16 (b) is a three-step inquiry. First, as a threshold factor, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. In this regard, the Board must compare the level of severity and symptomatology of the claimant’s service-connected disability with the established criteria found in the Schedule for that disability. See Id. If the rating criteria reasonably describe the claimant’s disability level and symptomatology, then the claimant’s disability picture is contemplated by the Schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are found to be inadequate to evaluate the claimant’s disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, then under the third step of the inquiry the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the claimant’s disability picture requires the assignment of an extraschedular rating. Id. During the period on appeal, the Veteran’s service-connected disability picture did not present such an exceptional circumstance to warrant further analysis for a referral. The medical findings of anxiety, difficulty adapting to a stressful situation, mild memory loss and impaired concentration were “like or similar to” those explicitly listed the rating criteria, which considers symptoms such as impairment of health, incapacitation episodes, and chronic residuals. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). In view of the circumstances, the Board finds that the rating schedule was adequate and further analysis with regards to a referral for extraschedular consideration is not needed under the circumstances of this case. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). The claim for TDIU since November 12, 2010, is denied. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Anwar, Attorney-Advisor 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.