Citation Nr: 0001169 Decision Date: 01/13/00 Archive Date: 01/27/00 DOCKET NO. 92-01 242 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an increased rating for fibromyalgia/fibromyositis with a somatoform disorder, currently evaluated as 20 percent disabling. 2. Entitlement to a total disability rating for individual unemployability (TDIU) based upon service-connected disabilities. REPRESENTATION Appellant represented by: Missouri Veterans Commission WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Wm. Kenan Torrans, Associate Counsel INTRODUCTION The veteran served on active duty from July 1953 to July 1957. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied the benefit sought. By Remands of August 1992, June 1995, July 1996, and October 1997, the Board referred the case to the RO for additional development. The case has now been returned to the Board for resolution. FINDINGS OF FACT 1. All evidence necessary for an equitable resolution of the issues on appeal has been obtained by the RO. 2. The objective medical evidence shows the veteran's somatoform disorder to be the predominant aspect of his service-connected disability with respect to fibromyalgia/fibromyositis with a somatoform disorder. 3. The physical aspect of the veteran's fibromyalgia/fibromyositis with a somatoform disorder is objectively shown to be productive of subjective complaints of chronic pain, fatigue, tenderness, and muscle stiffness, but is not shown to involve any functional limitation of a degree to warrant an evaluation in excess of the currently assigned evaluation. 4. The psychiatric aspect of the veteran's fibromyalgia/fibromyositis with a somatoform disorder is objectively shown to involve symptomatology most consistent with 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; and difficulty in establishing and maintaining effective work and social relationships. In addition, the psychiatric aspect of the veteran's service- connected disability is shown to be productive of symptomatology consistent with a considerably impaired ability to establish or maintain effective relationships with people. Further, by reason of psychoneurotic symptoms, the reliability flexibility, and efficiency levels are so reduced as to result in considerable industrial impairment. 5. The veteran's service-connected otitis-externa is objectively shown to be asymptomatic. 6. The veteran's service-connected disabilities are not shown to be so disabling as to preclude him from securing or following substantially gainful employment in keeping with his education and occupational experience. CONCLUSIONS OF LAW 1. The criteria for assignment of a 50 percent evaluation for the veteran's fibromyalgia/fibromyositis with a somatoform disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5025, 4.126(d), 4.130, Diagnostic Code 9423 (1999); 38 C.F.R. § 4.132, Diagnostic Code 9511 (1996). 2. The requirements for a total disability rating for individual unemployability due to service-connected disabilities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.1-4.14, 4.16, 4.18 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating The preliminary question before the Board is whether the veteran has submitted a well-grounded claim within the meaning of 38 U.S.C.A. § 5107(a) (West 1991), and if so, whether the VA has properly assisted him in the development of his claim. A mere allegation that a service-connected disability has become more severe is sufficient to establish a well-grounded claim for an increased rating. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 628, 632 (1992). Accordingly, the Board finds that the veteran has submitted a well-grounded claim. Once a claimant has submitted a well-grounded claim, the VA has a duty to assist him in developing facts which are pertinent to that claim. See 38 U.S.C.A. § 5107(a). The Board finds that all relevant facts have been properly developed, and that all evidence necessary for an equitable resolution of the issue on appeal has been obtained. The evidence includes the veteran's service medical records, records of treatment following service, transcripts of personal hearing testimony given before Hearing Officers at the RO and before the undersigned Board Member, reports of VA rating examinations, and personal statements by the veteran made in his own behalf. The Board is not aware of any additional evidence which is available in connection with the present appeal. Therefore, no further assistance to the veteran regarding the development of evidence is required. Disability evaluations are determined by evaluating the extent to which the veteran's service-connected disability affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.10 (1999). In addition, where entitlement to service connection has already been established, and an increase in a disability evaluation 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). In addition, disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examinations upon which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. The functional loss may be due to the absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. §§ 4.40, 4.45 (1999). Under DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995), the Board, in addition to applying the schedular criteria, may consider granting a higher evaluation in certain cases in which functional loss due to pain is demonstrated. Historically, service connection was granted for what was characterized as fibromyositis by a rating decision of November 1957. A 20 percent evaluation was assigned, effective from July 1957. In 1976, the veteran underwent a VA rating examination, and was not found to have any objective symptoms of his service-connected fibromyositis, and a noncompensable rating was assigned, effective from January 1977. In December 1990, the veteran filed a claim for an increased evaluation for his service-connected disability, contending that it had increased in severity. By a February 1991 rating decision, the veteran's assigned disability rating was increased to 20 percent, effective from April 1990. That 20 percent rating is the subject of this appeal. During the course of his appeal, the veteran's service- connected disability has been re-characterized as fibromyalgia, and he has also been found to have a somatoform disorder for which service connection has also been granted. The somatoform disorder is considered to be inextricably intertwined with the fibromyalgia and must be considered in rating the veteran's disability. Under 38 C.F.R. § 4.126(d) (1999), when a single disability has been diagnosed both as a physical condition and as a mental disorder, the rating agency must evaluate it using a diagnostic code representing the dominant (more disabling) aspect of the condition. The Board will therefore consider the veteran's claim on the basis of the physical and psychiatric aspects of the veteran's service-connected fibromyalgia/fibromyositis with a somatoform disorder, and will evaluate this disability on the basis of the dominant aspect of this condition. Id. In February 1991, the veteran underwent a VA rating examination in which he complained of experiencing pain on full range of motion in all of his extremities. On examination, he was not shown to have erythema, swelling, or tenderness. There was no significant limitation of motion noted in either hand. However, he was found to have muscle stiffness and tenderness to palpation in his hands. VA treatment records dating from June through November 1991 show that the veteran was seen throughout this period for complaints of pain and stiffness in his extremities. He was noted to complain of various symptoms including chest pain and general poor health, but he indicated that he was not depressed, but "just sick." In September 1991, the veteran was treated at a VA medical center (VAMC) on an inpatient basis for complaints of diffuse aches and pains. However, the treating physician noted that he demonstrated little, if any, objective findings commensurate with those subjective complaints. The veteran appeared at a personal hearing in November 1991 before a Hearing Officer at the RO, and testified that he experienced chronic aches and pains all over his body. He indicated that some days he felt better, and some days he felt worse, but that over the past several years, he felt "absolutely terrible." He treated his pain with Motrin. The veteran indicated that he had not worked for the past three years, and had last worked as an insurance salesman. He indicated that his symptoms included swollen joints, muscle wasting throughout all extremities, and that he unsuccessfully attempted to exercise. In September 1992, the veteran underwent a VA rating examination in which he complained of fatigue, pain, weakness, chronic dyspnea, and nausea. On examination, the examiner noted the veteran's complaints of pain and of "feeling bad" and also noted what was termed "generalized tenderness." The veteran was shown to have full range of motion in his extremities, but was noted to have poor fist formation and grip. The examiner indicated that such problems with the veteran's hands were either due to poor muscle strength or poor effort. However, he was unable to determine the cause of the veteran's alleged weakness. No tissue loss, muscle penetrations, tendon, nerve or bone damage were found, but the examiner noted a general loss of muscle strength. The examiner also observed that the veteran complained of tenderness whenever he was physically touched. Contemporaneous clinical treatment records dating from June 1991 through May 1994 show that the veteran was seen for complaints of "feeling terrible" and that he had reported that he had hypoglycemia. The veteran also indicated that he "hurt all over" and that Motrin provided no relief. During this period, the veteran also submitted two statements to the effect that mercury fillings in his teeth caused his physical problems, and that he was unable to work as a result. Treatment records also show that he had cardiac symptoms including a hyper-contractile small left ventricle with mitral valve prolapse. Treatment records from the Social Security Administration (SSA) dated in June and August 1991 show that the veteran presented with complaints of somatoform and personality disorders. During the course of a psychiatric evaluation, the veteran reported that he was unable to work because he was "sick." The examining physician observed that the veteran "moaned and groaned" throughout the course of the interview, and that he believed that his suffering was caused by mercury toxins in his teeth. The veteran complained of experiencing chronic fatigue syndrome, and that he was irritable and could not get along with others. The examiner offered his opinion that the veteran demonstrated obsessive/compulsive symptomatology, that he felt persecuted, and he actually suffered from hypochondriasis with somatic delusions. At the time of the interview, the veteran was noted to be poorly groomed and dressed, but he was able to hold an intelligent conversation. The examiner noted that he demonstrated superior verbal intelligence despite his frequent moans and groans. No looseness of association or evidence of a psychosis was found, and the examiner observed that it appeared as if the veteran's demonstrated slowness and pain symptomatology were designed for effect. With respect to his social life, the veteran was noted to belong to a model train club, and had one friend with whom he visited regularly. In addition, he also had several other people with whom he visited daily on the telephone. The examiner found that, on balance, the veteran demonstrated mild impairment in his concentration, but was able to maintain focus despite secondary depression. According to the examiner, the veteran's main problem involved fatigue which was associated with his belief in mercury poisoning. The examiner further found that the veteran was unable to relate to supervisors in a work environment due to his preoccupation with individual suffering and being in great distress. With respect to the veteran's overall psychiatric symptomatology, the examiner noted that the veteran's passive/aggressive or obsessive/compulsive behavior may have been demonstrative of some sort of attempts to manipulate others. The SSA examiner concluded with diagnoses of Axis I severe hypochondriasis, but also noted that he was unable to rule out a somatic reaction. The examiner offered his opinion that hypochondriasis was a more plausible diagnosis and that he favored it over other diagnoses including somatic disorders. In addition, the examiner offered an Axis V global assessment of functioning (GAF) score of 30, secondary to the veteran's diagnosed severe hypochondriasis. Under the standards set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a GAF score of 30 suggests behavior which is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment. In December 1995, the veteran underwent a VA rating examination in which he repeated his complaints of chronic muscle pain and stiffness, and reported that he had been informed that he had an attitude problem. The veteran also reported having attended a fibromyalgia support group to help him cope with his disability. The examiner found the veteran to be unkempt, and observed that the veteran "moaned and groaned" throughout the course of the examination, and on even the slightest movement or palpation. The veteran was noted to have psoriasis on his elbow. In addition, the examiner noted that the veteran had calluses on his hands from working. He observed later that the calluses were the result of engaging in strenuous activity. On examination, the veteran was not found to have any swelling, deformity, or bone disease. He showed multiple muscle tenderness, and his diagnoses included fibromyalgia. The examiner further found that the veteran's reported pain and other symptoms far exceeded his physical examination and laboratory findings. The veteran had normal range of motion in all extremities, and did not have any impairment of his knees. The examiner again noted that the veteran's calluses on his hands denoted strenuous activity involving his hands, and that pain was his only real symptom. He went on to state that the veteran's fibromyalgia should generally not affect his employability. The report of the veteran's latest physical examination, conducted in September 1996 with a February 1997 addendum shows that the veteran had attended the ninth grade in high school. He was found to be of casual appearance, and had fair judgment, questionable insight, a tense affect, poor concentration, and low energy. The veteran denied experiencing depression, suicidal ideation, crying, or mood swings. He was not found to experience hallucinations, paranoia, phobias, guilt or anger. The examiner observed that the medical evidence showed that an enormous amount of psychiatric symptomatology overlay his fibromyalgia. Further, in his February 1997 addendum, the examiner stated that the veteran had a somatoform disorder which was caused by his service-connected fibromyalgia. He concluded with an Axis I diagnosis of somatoform pain disorder, and repeated an earlier diagnosis that the veteran's symptoms were out of all proportion to the pathology of his fibromyalgia. He also offered an Axis V GAF score of 50, which is suggestive of serious psychiatric symptomatology or any serious impairment in social, occupational, or school functioning. The physical portion of the rating examination shows that the veteran complained of experiencing pain all over his body which precluded him from working. On examination, the veteran was not found to have any physical limitations due to his fibromyalgia, and no physical deformities, per se. He was diagnosed with fibromyalgia, and the examiner again observed that the veteran's symptoms and complaints were out of all proportion to fibromyalgia. The examiner also stated that the veteran did not have fibromyositis, and that his symptomatology was not related to any of his activities he had experienced while serving in the Navy. The veteran's ears were also examined, and were found to be completely normal. There was evidence of excessive cleaning, and the veteran showed evidence of clear, shiny epithelial tissue. The examiner concluded with a diagnosis of chronic otitis externa by history. He observed that there was currently no evidence of active infection. In June 1997, the veteran underwent his second personal hearing before a Hearing Officer at the RO. His testimony primarily consisted of subjective complaints of chronic pain and suffering from various causes, including his service- connected fibromyalgia. He also testified that his disability precluded him from obtaining or retaining gainful employment. The veteran appeared before the undersigned Board Member in July 1999, and essentially reiterated his prior complaints of chronic pain throughout his body. He testified that medications did not relieve his pain, and that he did not want to rely on narcotic painkillers due to the addictive effects of the drugs. In addition, the veteran indicated that his last regular employment ended in 1967 when he worked in electronics. He stated that not held a steady job since that time, and that his fibromyalgia precluded him from obtaining any sort of gainful employment. The Board has evaluated the evidence of record, and concludes that after taking the psychiatric and physical effects of the veteran's service-connected disability into consideration, the dominant aspect of his fibromyalgia/fibromatosis with a somatoform disorder appears to be psychiatric in nature. The Board finds, in substance, that the evidence shows that aside from subjective complaints of pain and weakness, the degree of which are, according to several examiners, of somewhat questionable validity, the veteran's fibromyalgia/fibromatosis with a somatoform disorder does not involve a physical impairment to a compensable degree. However, the evidence shows that his somatoform disorder is significantly disabling. At the time the veteran's fibromyalgia/fibromyositis was initially rated, there was no specific rating criteria dealing with that disorder. Therefore, during the time in which the disability at issue was characterized as fibromyositis, the disorder was evaluated by analogy to the criteria set forth under a related diagnostic code. Under Diagnostic Code 5021, the severity of myositis, rated as degenerative arthritis under Diagnostic Code 5003, is determined by consideration of the limitation of motion of the body part affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5021 (1999). In the absence of limitation of motion, a 20 percent rating is warranted when there is radiographic evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations; a 10 percent rating is assigned when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (1998). However, fibromyalgia is now evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5025 (1999). Under that diagnostic code, fibromyalgia involving widespread musculoskeletal pain and tender points, with or without sleep disturbance, stiffness, paresthesia, headache, irritable bowel symptoms, depression, anxiety, Reynaud's-like symptoms: requiring continuous medication for control warrants assignment of a 10 percent evaluation. A 20 percent evaluation is contemplated for fibromyalgia symptoms involving the above-listed symptoms that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time. A 40 percent evaluation, the highest rating available under Diagnostic Code 5025, is warranted upon a showing of the above-listed symptoms that are constant, or nearly so, and are refractory to therapy. Id. The evidence, consisting of clinical treatment records dating from February 1991 through April 1995, and VA rating examination reports dated in February 1991, September 1992, December 1995, and September 1996 show that the veteran consistently complained of aches, pains, fatigue, and related symptoms. He was generally found to have full range of motion in all extremities, but any motion undertaken was frequently accompanied by complaints of pain. The veteran was found to have a generalized tenderness, but no muscle wasting, tissue loss, weakness, or loss of strength was noted. The Board observes that in September 1992, the veteran was noted to have poor grip strength and fist- formation ability, but the examiner who conducted the December 1995 rating examination specifically noted that the veteran had calluses on both hands, which was indicative of heavy manual labor. The Board further observes that during his inpatient stay at the VAMC in September 1991, the veteran's complaints of diffuse aches and pains had little, if any objective findings to go along with those complaints. On balance, the Board concludes that the veteran's objectively demonstrated symptomatology as reflected by the medical evidence does not reveal a physical disability to the degree of severity he has reported. In support of this conclusion, the Board notes the opinions offered and repeated by the VA examiners who conducted the rating examinations of December 1995 and September 1996 that the veteran's symptoms were out of all proportion to the pathology of his fibromyalgia. Therefore, after resolving all reasonable doubt in favor of the veteran, and taking the effects of painful motion into consideration, the Board finds that the veteran's symptomatology warrants assignment of no more than a 20 percent evaluation under Diagnostic Code 5025 or any other applicable code. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. However, now that service connection has been granted for a somatoform disorder which is inextricably intertwined with the veteran's service-connected fibromyalgia/fibromyositis, this disorder must also be evaluated under the relevant criteria. Under the criteria for evaluating psychiatric disorders in effect when the veteran initially filed his claim, a noncompensable evaluation was contemplated upon a showing of neurotic symptoms which may have somewhat adversely affected relationships with others, but which did not cause impairment of working ability. See 38 C.F.R. § 4.132, Diagnostic Code 9511 (1996). Assignment of a 10 percent evaluation was warranted upon a showing of emotional tension or other evidence of anxiety productive of mild social and industrial impairment, but involving symptomatology of a lesser degree of severity than that required for assignment of a 30 percent evaluation. A 30 percent evaluation was contemplated for definite impairment in the ability to establish or maintain effective and wholesome relationships with people. The psychoneurotic symptoms resulted in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. For assignment of a 50 percent evaluation, there was to have been a showing of a considerably impaired ability to establish or maintain effective or favorable relationships with people. By reason of psycho-neurotic symptoms, the reliability, flexibility and efficiency levels were so reduced as to result in considerable industrial impairment. Id. A 70 percent evaluation was warranted upon a showing of a severely impaired ability to establish and maintain effective or favorable relationships with people. The psycho-neurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. Assignment of a 100 percent evaluation was contemplated for a psychoneurotic disorder in which the attitudes of all contacts except for the most intimate were so adversely affected as to result in virtual isolation in the community. Totally incapacitating psycho-neurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior was required. Also, the veteran was to have been demonstrably unable to obtain or retain employment. Id. In addition, in Johnson v. Brown, 7 Vet. App. 95 (1994), the United States Court of Appeals for Veterans Claims (Court) held that a showing of any one of the above evaluative criteria for a 100 percent evaluation was a sufficient basis upon which to award a 100 percent evaluation. By regulatory amendment, which became effective from November 7, 1996, substantive changes were made to the schedular criteria for evaluating psychiatric disorders, previously set forth in 38 C.F.R. §§ 4.125-4.132. See 61 Fed. Reg. 52695- 52702 (1996). The revised regulations pertaining to the evaluative criteria for psychiatric disorders, in this case an undifferentiated somatoform disorder, are now codified at 38 C.F.R. § 4.130, Diagnostic Code 9423 (1999). When the law or regulations change during an appeal period, the version most favorable to the claimant applies, absent congressional intent to the contrary. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). As service connection was granted for a somatoform disorder during an appeal which began prior to November 7, 1996, his claim must be evaluated under both the former and the revised criteria. However, where the amended regulations expressly provide an effective date and do not allow for retroactive application, the veteran is not entitled to consideration of the amended regulations prior to the established effective date. See Rhodan v. West, 12 Vet. App. 55 (1998); see also 38 U.S.C.A. § 5110(g) (West 1991). Under the revised criteria, a noncompensable rating is contemplated upon a showing that a mental condition has been formally diagnosed, but the symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent evaluation is warranted where there is 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 continuous medication. Assignment of a 30 percent evaluation is contemplated for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although 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, or recent events). A 50 percent evaluation is assigned upon a showing of 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- or long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances in motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Assignment of a 70 percent evaluation is contemplated where there is 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 worklike setting); and inability to establish or maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent danger of hurting oneself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9423 (1999). Applying both the former and the revised regulations governing psychiatric disorder evaluations, the Board concludes that the veteran's demonstrated symptomatology with respect to his undifferentiated somatoform disorder warrants assignment of a 50 percent evaluation. As noted the VA examiner who had conducted the September 1996 rating examination concluded in his addendum of February 1997 that the veteran's somatoform disorder was caused by his service- connected fibromyalgia. The Board further concludes that the veteran's somatoform disorder is the dominant aspect of his overall disability picture with respect to fibromyalgia/ fibromyositis. The Board finds that while the veteran's symptomatology is not entirely consistent with the criteria contemplated for a 50 percent rating under either the former or the revised standards, his symptomatology most nearly approximates the evaluative criteria for a 50 percent evaluation. As noted, the veteran's symptomatology surrounding his fibromyalgia has not been shown to involve significant physical characteristics, but rather involves primarily subjective complaints of pain, weakness, stiffness, fatigue, etc. In any event, his overall symptomatology suggests that he has some occupational and social impairment due to impaired memory and judgment, with disturbances of motivation and mood. Such a disability picture is consistent with the criteria for assignment of a 50 percent evaluation under the revised criteria. The record shows that the veteran underwent his first psychiatric examination in August 1991, which was provided by the SSA. At that time, he was diagnosed with Axis I severe hypochondriasis, and was assigned an Axis V GAF score of 30. However, while the examiner's conclusion suggests that this disability was effectively totally disabling, such finding was primarily based on the veteran's delusional belief that mercury fillings in his teeth were causing his chronic fatigue and other symptomatology. His service-connected fibromyalgia was not discussed in any detail during the course of that examination, and, in any event, the examiner largely discounted any delusional somatoform disorder. The VA psychiatric and physical examinations conducted in September 1996 show that the veteran's complaints of pain and other symptomatology were out of all proportion to the pathology of his fibromyalgia/fibromyositis. He was found to have a casual appearance with fair judgment, although he had a tense affect, poor concentration, and low energy. The Board also notes that while the September 1996 examination report fails to discuss the social aspects of the veteran's life, he was noted earlier to belong to a model train club, and that he had one friend with whom he visited daily, and three other friends with whom he visited daily on the telephone. Further, he has consistently denied experiencing depression, suicidal ideation, crying, and mood swings. He is not shown to experience hallucinations, paranoia, phobias, guilt, or anger. Moreover, no treating or examining physician has offered any opinion that the veteran's fibromyalgia/fibromyositis with a somatoform disorder has rendered him unemployable. For these reasons, the Board finds that the veteran has not met any of the criteria for assignment of a 100 percent evaluation under the former criteria. See 38 C.F.R. § 4.132, Diagnostic Code 9511 (1996); Johnson, 7 Vet. App. at 95. Likewise, the veteran's ability to establish and maintain effective or favorable relationships with people is not shown to be severely impaired. Further, as noted, he has not been shown to be incapable of engaging in gainful employment due to his service-connected disability. Therefore, the Board finds that the criteria for assignment of a 70 percent evaluation have not been met under the former criteria. Id. However, given the veteran's demonstrated symptomatology involving subjective complaints of constant aches and pains throughout his body, the Board finds that after resolving all reasonable doubt in his favor, the veteran could reasonably characterized as having considerable industrial impairment. Such a finding would satisfy the requirement for assignment of a 50 percent evaluation under the former rating criteria, although it is questionable whether he could be characterized as having a considerably impaired ability to establish or maintain effective or favorable relationships with people. See 38 C.F.R. § 4.132, Diagnostic Code 9511 (1996). Further, under the revised criteria, the Board finds that the veteran does not meet the criteria for assignment of either a 100 or a 70 percent evaluation for his undifferentiated somatoform disorder. The veteran is not objectively shown to have total social or occupational impairment due to such factors as delusions or hallucinations, and he is not shown to manifest symptoms such as memory loss for his own name, occupation, or other basic elements of his life. He has denied experiencing suicidal ideation, and while his personal hygiene has been shown to be somewhat lacking at times, he is not shown to be incapable of meeting such basic needs. For these reasons, the Board finds that the criteria for assignment of a 100 or 70 percent evaluation under the revised criteria have not been met. See 38 C.F.R. §§ 4.126(d); 4.130, Diagnostic Code 9423 (1999). II. TDIU The law provides that a total disability rating may be assigned where the schedular rating is less than total, where the disabled person is unable to secure or follow a substantially gainful occupation as a result of his service- connected disabilities. However, this is provided that if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 340, 341, 4.16(a) (1999). The issue of unemployability must be determined without regard to advancing age of the veteran. See 38 C.F.R. §§ 3.341(a), 4.19 (1999). Marginal employment shall not be considered substantially gainful employment. See 38 C.F.R. § 4.16(a). Factors to be considered are the veteran's education, employment history, and vocational attainment. See Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). As discussed more fully above, the veteran is currently service-connected for fibromyalgia/fibromyositis with a somatoform disorder, now evaluated as 50 percent disabling, and for chronic otitis externa, currently assigned a noncompensable rating. The veteran's otitis externa is evaluated under 38 C.F.R. § 4.87, Diagnostic Code 6210 (1999), which contemplates assignment of a 10 percent evaluation upon a showing of swelling, dry and scaly or serous discharge, and itching requiring frequent and prolonged treatment. As noted, the September 1996 rating examination report found the veteran's ears to be asymptomatic. Accordingly, a compensable evaluation is not warranted. He now has a combined disability rating of 50 percent. The Board is also satisfied, as discussed above, that the veteran's disabilities are correctly evaluated for purposes of determining whether unemployability exists, and that based on the evidence of record, his overall disability picture does not entitle him to a schedular evaluation higher than the 50 percent currently in effect for his service-connected disabilities. Simply, the veteran does not meet the percentage requirements for a total disability evaluation. That not withstanding, it is the established policy of the VA that all veterans who are unable to secure or follow a substantially gainful occupation by reason of service- connected disabilities shall be rated as totally disabled. Therefore, at the RO level, rating boards are to submit to the Director, Compensation and Pension Service, for extra schedular consideration, all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16(a). The rating board is to include in its submission a full statement as to the veteran's service- connected disabilities, employment history, level of vocational attainment, and other factors bearing on the issue. See 38 C.F.R. § 4.16(b) (1999). Given that the veteran has a combined disability rating of 50 percent, he does not meet the statutory requirement for basic eligibility for an award of TDIU on a schedular basis. Accordingly, the Board must consider the veteran's claim for individual unemployability on an extra-schedular basis. As noted, the Board recognizes that the veteran is currently in receipt of a nonservice-connected pension for his nonservice- connected personality disorder with hypochondriasis, which was rated as 70 percent disabling in May 1995. In addition, the Board acknowledges that the veteran has not worked since at least 1988. However, any inability the veteran may experience in obtaining or retaining gainful employment is not shown by the objective medical evidence to be the result of his service- connected disabilities. The evidence shows that the veteran attended high school through the ninth grade, and had earned his GED while in the service. He was trained in sonar systems in the Navy, and worked for a period in electronics, as a mechanic, and later in insurance sales. The evidence also shows that he has been treated for disorders other than those for which he is service connected. There does not appear to be any objective opinion of record, medical or otherwise, which states that the veteran is unemployable due specifically to his service-connected disabilities. He has reported that he is barely able to take care of basic necessities and cannot effectively use his hands. However, the report of the December 1995 rating examination contains the examiner's express observations that the veteran had calluses on both hands, which had resulted from heavy manual labor. In addition, the examiner stated that the veteran's service-connected fibromyalgia/ fibromyositis should generally not affect his employability. Further, while the veteran's nonservice-connected pension is based primarily on a personality disorder with hypochondriasis, which is rated as 70 percent disabling, service connection is not in effect for that disorder. Moreover, the report of the SSA examination of September 1991, upon which the decision to grant a nonservice-connected pension was based, included the examiner's opinion that the veteran's debilitating disability was due, in large part, to his delusional belief that mercury fillings in his teeth were poisoning his body. Most significantly, no physician has offered the opinion that the veteran is incapable of working due to his service-connected disabilities. The Board has considered the statements and testimony by the veteran that he is completely unemployable due to his service-connected disabilities, but finds such assertions to be unsupported by the medical evidence. The Board concludes, therefore, that the veteran is not shown to be precluded from all types of substantially gainful employment by reason of his service-connected disabilities. Accordingly, the Board finds that he is not entitled to a total disability evaluation based on individual unemployability. ORDER Subject to the applicable laws and regulations governing the award of monetary benefits, a 50 percent evaluation is assigned for the veteran's fibromyalgia/fibromyositis with a somatoform disorder. A total disability rating for individual unemployability based upon service-connected disabilities is denied. S. L. KENNEDY Member, Board of Veterans' Appeals