Citation Nr: 0007430 Decision Date: 03/20/00 Archive Date: 03/23/00 DOCKET NO. 98-10 194 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for heart disease, claimed as secondary to service connected post-traumatic stress disorder. 2. Entitlement to service connection for a gastrointestinal disorder, claimed as secondary to service connected post- traumatic stress disorder. 3. Entitlement to an increased rating for post-traumatic stress disorder, currently evaluated as 30 percent disabling. 4. Entitlement to a total rating for compensation based on individual unemployability. REPRESENTATION Appellant represented by: Tennessee Department of Veterans' Affairs ATTORNEY FOR THE BOARD E. W. Koennecke, Associate Counsel INTRODUCTION The appellant served on active duty from January 1969 to December 1970. This case comes before the Board of Veteran's Appeals (the Board) on appeal from a November 1997 rating decision of the Nashville, Tennessee, Department of Veterans Affairs (VA) Regional Office (RO). FINDINGS OF FACT 1. Competent evidence that heart disease is proximately due to or aggravated by post-traumatic stress disorder has not been presented. 2. Competent evidence that gastrointestinal disease is proximately due to or aggravated by post-traumatic stress disorder has not been presented. 3. Post-traumatic stress disorder is manifested by no more than intermittent periods of inability to perform occupational tasks due to depressed mood, anxiety and chronic sleep impairment. 4. Service connection is in effect for post-traumatic stress disorder and assigned a 30 percent evaluation. CONCLUSION OF LAW 1. The claim for service connection for heart disease is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim for service connection for gastrointestinal disease is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. Post-traumatic stress disorder is no more than 30 percent disabling. 38 U.S.C.A. § 1155, 5107(b) (West 1991); 38 C.F.R. Part 4, § 4.130, Diagnostic Code 9411 (1999). 4. The criteria for a total disability rating for compensation based on individual unemployability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.16 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service Connection Claims The issues on appeal stem from a denial by the RO of service connection for heart disease or a gastrointestinal disorder, claimed as secondary to service connected post-traumatic stress disorder. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease. 38 U.S.C.A. §§ 1110, 1131 (West 1991). 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 disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (a) (1999). Additional disability resulting from the aggravation of a non-service- connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439 (1995). A well-grounded claim for service connection generally requires medical evidence of a current disability; evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, a nexus, or link, between the inservice disease or injury and the current disability as provided by competent medical evidence. Cohen v. Brown, 10 Vet. App. 128, 137 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995) aff'd per curiam, 78 F.3d 604 (Fed.Cir. 1996) (table); see also 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (1998); Layno v. Brown, 6 Vet. App. 465 (1994); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Alternatively, the nexus between service and the current disability can be satisfied by evidence of continuity of symptomatology and medical or, in certain circumstances, lay evidence of a nexus between the present disability and the symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495 (1997). Establishing direct service connection for a disability that was not clearly present in service requires the existence of a current disability and a relationship or connection between that disability and a disease contracted or an injury sustained during service. Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Moreover, establishing a well-grounded claim for service connection for a particular disability requires more than an allegation that the particular disability had its onset in service. It requires evidence relevant to the requirements for service connection cited above and of sufficient weight to make the claim plausible and capable of substantiation. Tirpak v. Derwinski, 2 Vet. App. 609 (1992); see also Murphy, 1 Vet. App. at 81. The kind of evidence needed to make a claim well grounded depends upon the types of issues presented by the claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). For some factual issues, competent lay evidence may be sufficient. However, where the claim involves issues of medical fact, such as medical causation or medical diagnoses, competent medical evidence is required. Grottveit, 5 Vet. App. at 93. For cases involving secondary service connection, competent evidence that heart disability or gastrointestinal disability is proximately due to or the result of post-traumatic stress disorder or was aggravated by service-connected post-traumatic stress disorder would be necessary to well ground this claim. See Allen, 7 Vet. App. at 439. In a statement submitted in September 1999, the appellant clarified that his claim was for secondary service connection. The appellant contended that the symptoms associated with post-traumatic stress disorder puts stress on his heart, which is known to be the number one factor in causing heart disease. He further contended that his constant state of stress, depression, anxiety and other symptoms have caused his digestive disorders. The appellant's cardiovascular system and gastrointestinal system were normal at the time of a pre-induction examination in April 1968 and a separation examination in December 1970. In May 1985 the appellant was referred to Hickman County Mental Health Clinic for eating and sleep disturbances. The appellant reported irritability, an exaggerated startle response and a 30-lb. weight loss. Post-traumatic stress disorder was diagnosed. He was evaluated in November 1989 for left arm pain. He reported a history of epigastric discomfort when he ate spicy foods. On examination his heart exhibited normal rate and rhythm without murmurs, gallops or rubs. His abdomen was soft, nontender with active bowel sounds. No masses were felt. Cardiac origins of the left arm pain were to be ruled out. In July 1992 he was seen at a private hospital for complaints of abdominal pain and vomiting. There was diffuse tenderness in the abdomen. Bowel sounds were positive and no masses were felt. Acute gastroenteritis was diagnosed. He was evaluated in August 1994 by Dr. C. for chest pain with both typical and atypical features for myocardial ischemia. There was no previous cardiac history. On cardiac examination his heart had a normal rate and rhythm without murmurs, gallops or heaves. His electrocardiogram revealed a normal sinus rhythm without acute ischemic changes. His abdominal examination was benign. The appellant complained of shortness of breath in September 1994. A previous cardiac work-up had revealed a normal sinus rhythm with a normal electrocardiogram. There was no acute cardiopulmonary disease on examination. An echocardiogram in October 1994 showed an ejection fraction of 40 percent with mild thickening of the right ventricular walls. The assessment was paroxysmal episodic shortness of breath secondary to post-traumatic stress disorder. As part of an application for Social Security Administration benefits in February 1995, the appellant completed a fatigue and activities of daily living questionnaire. The appellant reported fatigue due to the medication he was taking and difficulty sleeping. He stayed at home and away from other people as much as possible as he could not deal with people of the frustrations of daily life. He reported chronic back pain. He cared for his wife, parents, and dog and spent his time doing light household chores, watching television, reading, napping and preparing meals. On VA examination in April 1995, his heart showed a regular rate and rhythm with normal S1 and S2. There were no murmurs, rubs or gallops. There was no evidence of cardiac hypertrophy on examination. Blood pressure was 118/74. His abdomen was soft and nontender without masses or hepatosplenomegaly. He had normoactive bowel sounds and no hernias. He was diagnosed with a history of irritable bowel syndrome, post-traumatic stress disorder and mildly decreased left ventricular ejection fraction by echocardiogram. In August 1997, the appellant was admitted to the VA Medical Center to rule-out a myocardial infarction. He was free of chest pain during admission and an exercise treadmill test was negative for ischemia. His discharge diagnosis was non- cardiac chest pain. VA Medical Center notes from September 1997 indicated he had experienced chest pain with shortness of breath the prior month, with none since. He reported stomach problems since beginning a new drug. He was nauseated if he did not eat, and when he ate he usually vomited before finishing the meal. Questionable regurgitation was noted. He had a history of hematemesis a few years prior while drinking. He reported diarrhea with 5 to 6 stools per day. He had diarrhea for more than 20 years, and now he was having it in the early morning. On examination his heart had a regular rate and rhythm. His abdomen was obese, with active bowel sounds. It was nontender and no masses were felt. On rectal examination there were no masses and stool was guaiac negative. The appellant was scheduled for further studies to rule-out peptic ulcer disease, lower gastrointestinal disease, irritable bowel syndrome, atypical chest pain and alcoholic cardiomyopathy. A VA examination was conducted in October 1997. The examiner concluded that the appellant had a past history of a cardiac defect and left ventricular dyskinesias that impacted on his functional status. These conditions were not related to post-traumatic stress disorder and were most likely caused by his strong family history of myocardial infarctions. His digestive complaints were most consistent with irritable bowel disease. The appellant failed to report for scheduled endoscopy. In VA Medical Center notes from 1997, the appellant complained of abdominal pain, heartburn, reflux and vomiting. Colonoscopy in October 1997 was said to show severe dysplasia in the tip of a polyp, later removed. On examination his heart exhibited normal rate and rhythm. His abdomen was soft, nontender and nondistended. On esophagogastroduodenoscopy in December 1997 there was distal esophagitis with ulceration, antral erosions in his stomach likely secondary to nonsteroidal antiinflammatory drugs, and a normal duodenum. His weight was stable. Hypertension was diagnosed. Abnormalities were demonstrated on endoscopy in January 1998. At the conclusion of a VA examination for post-traumatic stress disorder in March 1999, the examiner stated that the appellant had concomitant medical problems that appeared to confound his mental health including coronary artery disease. Abnormalities were demonstrated on endoscopy in September 1999. The appellant has specifically stated that his claims are for secondary service connection. Therefore, the Board will only briefly note that as heart disease or a digestive disorder was not shown in service, and competent evidence linking heart disease or a digestive disorder to service has not been presented, the claim for service connection on a direct basis is not well grounded. The claims for service connection for heart disease or a gastrointestinal disease as secondary to service connected post-traumatic stress disorder are not well grounded. No competent examiner has stated that heart disease (to include hypertension or myocardial infarction), or gastrointestinal disease (to include esophagitis, stomach erosion or irritable bowel disease) are proximately due to or the result of post-traumatic stress disorder. No competent examiner has indicated that the appellant has additional disability resulting from the aggravation of his heart disease, or gastrointestinal disease due to post-traumatic stress disorder. The examiner in October 1997 stated that cardiac disease was not related to post-traumatic stress disorder, but to a strong family history of such. Stomach erosions have been attributed to the use of nonsteroidal antiinflammatory drugs, and there has been no evidence presented that these were prescribed for the treatment of post-traumatic stress disorder. A psychiatric examiner opined in March 1999 that the appellant's medical problems including coronary artery disease confounded his mental health. This is the reverse of what would be necessary to have a well grounded claim for secondary service connection. In other words, having competent evidence that demonstrates that heart disease appears to confound or even aggravate the appellant's psychiatric state is not the same as having competent evidence that demonstrates that heart disease is the result of post-traumatic stress disorder or that heart disease has been aggravated by post-traumatic stress disorder. The appellant has contended that the symptoms associated with post-traumatic stress disorder have aggravated or caused his heart and gastrointestinal disease. In a secondary service connection claim, the question centers on the relationship of one condition to another. Such a relationship is not susceptible to informed lay observation and thus, for there to be credible evidence of such a relationship, medical evidence is required. See, e.g., Reiber v. Brown, 7 Vet. App. 513, 516 (1995). The appellant lacks the medical expertise to comment on such a relationship. The claims for service connection for heart disease or a gastrointestinal disorder claimed as secondary to post- traumatic stress disorder are not well grounded. When the veteran has not met this burden, VA has no further duty to assist him in developing facts pertinent to his claim, including no duty to provide him with another medical examination. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Although when a claim is not well grounded VA does not have a statutory duty to assist a claimant in developing facts pertinent to the claim, VA may be obligated under 38 U.S.C.A. § 5103(a) to advise a claimant of evidence needed to complete his or her application. This obligation depends on the particular facts of the case and the extent to which the Secretary has advised the claimant of the evidence necessary to be submitted with a VA benefits claim. Robinette v. Brown, 8 Vet. App. 69 (1995). Here, the VA fulfilled its obligation under section 5103(a) in the Statement of the Case issued in May 1998 and the Supplemental Statement of the Case issued in July 1999. In this respect, the Board is satisfied that the obligation imposed by section 5103(a) has been satisfied. See Franzen v. Brown, 9 Vet. App. 235 (1996) (VA's obligation under sec. 5103(a) to assist claimant in filing his claim pertains to relevant evidence that may exist or could be obtained). See also Epps v. Brown, 9 Vet. App. 341 (1996) (sec. 5103(a) duty attaches only where there is an incomplete application that references other known and existing evidence that pertains to the claim under consideration) and Wood v. Derwinski, 1 Vet. App. 190 (1991) (VA's duty is just what it states, a duty to assist, not a duty to prove a claim). The record reflects that the veteran changed his theory of entitlement to include service connection for dysplastic colonic polyps as due to Agent Orange exposure and as due to his service connected disability. The new theory was addressed by the RO and service connection for dysplastic colonic polyps claimed as a result of exposure to Agent Orange in service was denied in a May 1998 rating decision. The veteran was informed of the determination May 15, 1998. The veteran did not submit a notice of disagreement in a timely manner. Therefore, that decision is final. Regardless, even if the new theory were part of the original appeal, the amended claim would be not well grounded. The polyp disorder was not manifest in service or in proximity to service. The polyp disorder is not a presumptive Agent Orange disability, see 38 C.F.R. §§ 3.307, 3.309 (1999), and no competent professional has attributed the polyp disorder to service, to Agent Orange exposure or a service-connected disability. Although there is no universal presumption of exposure to Agent Orange, even if we accept exposure on a factual basis, the claim is not well grounded when there is no competent evidence linking the disorder to service. (Insert CVA case on no presumption) Since the issue was addressed by the RO, the veteran is not prejudiced by the Board's determination. See Bernard v. Brown, 4 Vet. App. 384 (1993). Increased Rating for Post-traumatic Stress Disorder Service connection for post-traumatic stress disorder was granted in September 1996 and a 30 percent evaluation was assigned. This claim stems from a November 1997 rating decision wherein the RO confirmed and continued a 30 percent evaluation for post-traumatic stress disorder. The claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). This finding is based on the appellant's contentions that his post-traumatic stress disorder has increased in severity. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The RO has met its duty to assist the appellant in the development of his claim. under 38 U.S.C.A. § 5107 (West 1991). Records were obtained from the VA Medical Center and identified private treatment sources. VA examinations were conducted in October 1997 and March 1999. Furthermore, there is no indication from the appellant or his representative that there is outstanding evidence which would be relevant to this claim. Disability evaluations are determined by the application of a schedule of rating which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Separate diagnostic codes identify the various disabilities. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (1999); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While evaluation of a service-connected disability requires review of the appellant's medical history, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Therefore, although the Board has reviewed all the evidence of record, it finds that the most probative evidence is that which has been developed immediately prior to and during the pendency of the claim on appeal. When all the evidence is assembled, the determination must then be made as to 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. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The appellant has contended that the symptoms associated with post-traumatic stress disorder have increased in severity. His treating physicians have constantly changed the drugs that he takes and have increased the amounts. His depression is worse, his feelings of stress are worse and he stays at a high level of anger due to the post-traumatic stress disorder. He continues to have problems dealing with life every day. He cannot concentrate on simple everyday tasks and his memory loss was increasing. He had periods of panic attacks and was becoming more irritable. He was unable to have normal sexual relations with his wife and had problems with alcohol. The criteria for evaluating post-traumatic stress disorder, 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999) are as follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name - 100 percent disabling. 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); inability to establish and maintain effective relationships - 70 percent disabling. Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships - 50 percent disabling. Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) - 30 percent disabling. 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 - 10 percent disabling. A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication - 0 percent disabling. In VA Medical Center notes from January 1997 the appellant reported sexual difficulties and an increased irritability with day-to-day events. On examination he was alert and oriented to person, place, time and date. He was mildly dysphoric and his affect was restricted. There was no psychosis. Dysthymia with increased anxiety and situational stressors was diagnosed. Post-traumatic stress disorder was said to be in remission. In April 1997 he reported being angry because his back pain was not being managed, but he was not willing to be evaluated because doctors would think he was just a drug addict. On examination he exhibited mild to moderate dysphoria and his affect was restricted. Post- traumatic stress disorder and dysthymia were diagnosed. In July 1997 he reported his post-traumatic stress disorder symptoms being worse in the summer. He was having trouble sleeping, flashbacks and nightmares. His energy was decreased due to heart disease and other medical problems. His head stayed cluttered and he could not concentrate. He was more irritable. On examination he was appropriately groomed and casually dressed. His speech had a normal rate and rhythm. His mood was down and his affect appropriate. There was no psychosis and he denied suicidal or homicidal ideation. Post-traumatic stress disorder and dysthymia were diagnosed. In August 1997 he reported that his nightmares had decreased and he was sleeping better with new medication. He still had nights when he was up all night. The examiner thought the appellant would benefit from group therapy. He was not working and had stopped using alcohol. He spent his time mowing grass when he felt like it. Post-traumatic stress disorder was diagnosed. A VA examination was conducted in October 1997. The examiner reviewed the entire claims folder including VA Medical Center treatment records. The examiner reported evidence and additional medical history since the prior 1995 VA examinations. The appellant reported that he felt he had an increase in symptoms while noting that he had obtained benefit from new medications. He denied changes in his family life and stated that although he got along well with his wife, he had no libido and they did not have sexual relations. His depression and anxiety were worse. His memory was worse. He had nightmares and flashbacks that brought on shortness of breath. He was not currently employed. He had worked all his life until all of this "stuff" came on. He last worked as a carpenter and was employed for one year. His longest job was for a sign manufacturer where he worked as a supervisor for 13 years until the company was sold. He had not used alcohol for 2 1/2 years until one week before the examination. As a result, he was arrested for driving under the influence of alcohol. On review of his psychiatric symptoms, he endorsed continuing flashbacks, avoidance behavior having to do with Vietnam, decreased memory and concentration, tension, fearfulness, worry, anger, irritability, chest pain, shortness of breath, palpitation, tremulousness and nervousness. He described ongoing feelings of sadness and depression with occasional crying spells. He denied suicidal or homicidal ideation or a history of self-destructive behavior. He has felt paranoid and withdrawn. He had a decrease in appetite and was awakened by nightmares every night. He had no libido. On mental status examination he had arrived promptly for his appointment. He was casually but neatly dressed. His mustache was neatly trimmed and he was otherwise clean- shaven. He was somewhat cautious and hesitant, but was a fair historian. He made good eye contact. He was able to remain seated for the entire examination. He showed a full range of affect that was appropriate to the content of the examination. He had a good sense of humor and responded to humor appropriately but cautiously. His affect was not labile or bizarre. He described his mood as depressed and nervous. He was alert and oriented to person, place, time and situation. There was no unusual psychomotor activity, gestures, or behavior. There was no deficit of cognition, memory, learning or attention. His thoughts were coherent and logical without flight of ideas or loose association. There was no suicidal or homicidal ideation. There was no evidence that he was experiencing auditory or visual hallucinations, delusions, paranoid or psychotic thought. There was no deficit of calculation, abstraction, similarities or general information. There was no evidence of organicity. His judgment was good. He had some psychological insight and was able to develop a good rapport with the examiner. He was diagnosed with continued post- traumatic stress disorder and alcohol dependence. His current and highest Global Assessment of Functioning score from the past year was 51-60. The examiner indicated that the appellant continued to endorse symptoms of a nature similar to those reported previously, although the appellant stated that the symptoms have increased in severity and frequency despite treatment. In November 1997 VA Medical Center notes, the appellant reported a recent problem with temper control, intrusive thoughts and combat nightmares. He had resumed episodic alcohol intake and had an incident with the police. He was very angry about this, and since the incident had been more angry and had more frequent nightmares. A VA examination was conducted in March 1999. The examiner had reviewed the appellant's history and claims folder, including the November 1997 rating decision that confirmed and continued the 30 percent evaluation for post-traumatic stress disorder. He reported that his stress, depression, nightmares, flashbacks and sleeping problems were worse and that his doctors had increased his medication for that reason. He had problems dealing with life on a day-to-day basis and could not concentrate. He reported problems with memory, mood fluctuations and sexual relationships. He had a history of charges for driving under the influence of alcohol prior to the 1997 incident and was on probation. He had stopped drinking. He slept 3 to 4 hours a night and had frequent nightmares. He had flashbacks to Vietnam 1 to 2 times a day that lasted minutes to hours. He described his mood as depressed, his energy low with anhedonia and occasional vague suicidal ideation. He denied suicidal or homicidal ideation at the time of the examination. He described frequent feelings of anxiety and anger over the Vietnam War. He described behavior such as isolation, although he had been married for 20 years and lived at home. He had been unemployed for approximately 4 years. Prior to that he had been employed in construction work but gave that up primarily due to his medical condition. Over the previous year he had tried construction and auction work, but he had poor physical health and poor concentration. He had been married twice. His first wife died of cancer in 1978 after seven years of marriage, and he had been married to his second wife for 20 years. He primarily stayed at home with his wife, who was also unemployed. He enjoyed watching NASCAR racing and reading. He also cared for elderly relatives. Poor sleep and chronic pain were his primary stressors. His depression had been worsening since a small heart attack. On mental status examination he was well groomed and in no acute distress. His speech was clear and concise. He denied auditory or visual hallucinations except for flashbacks. His mood was tired and depressed. His affect was mildly dysphoric but full. He was oriented to time, place and person. He provided accurate knowledge about the presidents. There was no sign of concrete thinking and he was able to abstract appropriately. He was able to recall three out of three objects on immediate recall as well as 5 minutes later. He denied suicidal or homicidal ideation and contracted for safety. Post-traumatic stress disorder, major depressive disorder and alcohol dependence in remission were the psychiatric diagnoses. His Global Assessment of Functioning score was 60. The examiner explained that the appellant appeared to have moderate symptoms of post-traumatic stress disorder and depression. His post-traumatic stress disorder symptoms included poor sleep, nightmare, and flashbacks. The depressive symptoms included poor energy, anhedonia, poor sleep, poor concentration and occasional vague suicidal ideation. He had apparently tried to do various jobs but was unsuccessful. He was able to enjoy certain activities and cared for elderly relatives. He had concomitant medical problems that appeared to confound his mental health, including chronic pain and coronary artery disease. The preponderance of the evidence is against the claim for a higher evaluation. Reliable evidence of flattened affect, speech disturbances, panic attacks more than once a week, difficulty understanding complex commands, memory impairment, impaired judgment, impaired thinking or difficulty in establishing and maintaining effective social relationships has not been presented. Multiple examiners as well as treatment providers have reported an affect appropriate to his mood, normal speech, normal memory, normal judgment and thinking. He has been married for 20 years, lives at home and cares for his aging relatives. Depressed mood has been reported by multiple examiners, however, this finding alone does not support a higher evaluation. The evidence does demonstrate that the appellant was generally functioning satisfactorily, with routine behavior, self-care and conversation normal on multiple examinations. His occupational and social impairment was repeatedly attributed to depressed mood and anxiety and his chronic sleep impairment. This reported symptomatology is consistent with the currently assigned evaluation. When there is a question as to which of two evaluations shall 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. 38 C.F.R. § 4.7 (1999). The appellant has reported panic attacks of a periodic nature, increased irritability and anger, and memory loss. The appellant is competent to state that his condition is worse. However, the training and experience of the medical personnel makes their findings more probative as to the extent of the disability. The examiner in March 1999 tested and noted that his memory for current events was normal and that he had total recall immediately and after 5 minutes, which contradicts the appellant's assertion that he has memory loss. The preponderance of the evidence is against the claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b), Gilbert v. Derwinski, 1 Vet. App. 49 53 (1990). The Board's conclusion is further supported by a Global Assessment of Functioning scores of 51-60 and 60 which were noted in the October 1997 and March 1999 VA examinations, respectively. Although the Global Assessment of Functioning score does not fit neatly into the rating criteria, the Global Assessment of Functioning score is also evidence. Carpenter v. Brown, 8 Vet. App. 240 (1995). Global Assessment of Functioning score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994). A Global Assessment of Functioning score between 51-60 is defined as exhibiting moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). The moderate nature of his disability picture, with the highest-end score reported on the most recent examination, is most consistent with the current evaluation. Total Rating for Compensation Based on Individual Unemployability The veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, his assertion that his service-connected disability has worsened to the extent that it renders him unemployable raises a plausible claim. See Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). All relevant facts have been properly developed. VA has completed its duty to assist the veteran in the development of his claim. See 38 U.S.C.A. § 5107(a). The appellant has indicated that he is in receipt of Social Security Administration benefits. The Board notes that all of the medical records upon which the Social Security Administration based their decision were developed by the RO. The RO also requested a copy of a decision that was made regarding the appellant's eligibility. There has been no statement from the appellant or his accredited representative that an administrative law judge made a decision in his case, and therefore there is no indication that there is any outstanding administrative law judge decision that could be obtained. In the September 1997 application for total rating for compensation based on individual unemployability, the appellant reported that he worked through July 1995 for a construction company and applied in July 1995 with the same company and was not hired. The appellant has not indicated that he was fired from that employer or given any other indication that there might be outstanding employment records regarding the company's refusal to rehire him. There has been no indication that he was evaluated for or received vocational rehabilitation training. The appellant has not reported that any other pertinent evidence might be available, accordingly the duty to assist has been fulfilled. See Epps v. Brown, 9 Vet. App. 341, 344 (1996). Total disability ratings for compensation purposes based on individual unemployability may be assigned where the combined schedular rating for a veteran's service-connected disabilities is less than 100 percent and when it is found that such disorders are sufficient to render the veteran unemployable. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.340, 3.341, 4.16, (1999). If there is only one such service-connected disability, it must be ratable at 60 percent or more, and if there are two or more service- connected disabilities, at least one must be rated at 40 percent or more with a combined rating of 70 percent or more. It is further provided that the existence or degree of nonservice-connected disabilities, or previous unemployability or age will be disregarded when the percentages referred to above are met. 38 C.F.R. §§ 4.16(a), 4.19 (1999). See Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). The record must reflect some factor that takes a particular case outside the norm in order for a claim for individual unemployability benefits to prevail. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. Van Hoose, 4 Vet. App. at 363. 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 can find employment. Moreover, the veteran's advancing age and non- service-connected disabilities may not be considered. See 38 C.F.R. § 3.341(a) (1999); Van Hoose, 4 Vet. App. at 363; Hersey, 2 Vet. App. at 94. In determining whether a particular veteran is unemployable, the Board must also give full consideration to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effect of combinations of disability. 38 C.F.R. § 4.15 (1999). Furthermore, the Board must consider the effects of the veteran's service-connected disability or disabilities in context of his employment and educational background. See Fluharty v. Derwinski, 2 Vet. App. 409, 412- 13 (1992). The appellant has contended that he had worked hard all his life until he became disabled. He was 51-years old, did not have a high school diploma, and with all of his medical problems, who would hire him? What the RO has said does not agree with what his doctors have told him. The appellant has reported a grant of Social Security Administration disability benefits. The medical evidence upon which the decision was based was reviewed. Private medical records between 1984 and 1995 document evaluation and treatment for cardiac complaints. Shortness of breath was attributed to anxiety in April 1990. VA Medical Center records that were submitted to the Social Security Administration from 1994 to 1995 document evaluation for cardiac symptoms and shortness of breath. Shortness of breath was attributed to anxiety and post-traumatic stress disorder. The Board has also reviewed the medical evidence submitted in support of the claim for an increased rating for post- traumatic stress disorder. In January 1997, the appellant indicated that he was not working. In October 1997 he indicated he had worked until all of this "stuff" had come on. He had last worked as a carpenter and his longest job was as a supervisor for 13 years until the company was sold. In March 1999 he reported that he had given up his prior construction work primarily due to his medical condition. He had tried other construction and auction work but he had poor physical health and poor concentration. The examiner indicated that he had tried to do various jobs but was unsuccessful. Global Assessment of Functioning scores have been reported between 51-60. The appellant completed two years of high school. He was self-employed in farm work from 1993-1994, and in construction work from 1991 to 1992, and from 1994 to 1995. He last worked in July 1995. Service connection is in effect for post-traumatic stress disorder, which is evaluated as 30 percent disabling. Thus, the appellant does not meet the requirements set forth in 38 C.F.R. § 4.16(a). Therefore, he has no legal merit to the claim based upon schedular requirements. The record reveals that the RO expressly considered referral of the case to the Chief Benefits Director or the Director, Compensation and Pension Service for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1999). This regulation provides that to accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. The governing criteria for such an award is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked inference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The U. S. Court of Appeals for Veterans Claims (known as the United States Court of Veteran's Appeals prior to March 1, 1999) (hereinafter Court) has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In July 1999 the RO found that there were no exceptional factors or circumstances associated with the appellant's disablement. Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. VAOPGCPREC. 6-96 (1996). No competent examiner has stated that the appellant is unemployable due to post-traumatic stress disorder. Any statement of the appellant as to what a doctor told him is insufficient to establish unemployability. The connection between what a physician said and the layman's account of what he purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute medical evidence. Robinette v. Brown, 8 Vet. App. 69, 77 (1995), Marciniak v. Brown, 10 Vet. App. 198 (1997). The appellant himself has stated that he ceased employment primarily due to his physical problems. The appellant has not been hospitalized for post-traumatic stress disorder and there is no competent evidence that it has produced marked interference with employment. The Board has considered his contentions, but the findings of the medical personnel are more probative. His disability falls within the 30 percent criteria for rating mental health disabilities. The Board's conclusion is further supported by the Global Assessment of Functioning scores of 51-60, which are indicative of moderate difficulty in occupational functioning. This is not unemployability. The preponderance of the evidence is against the claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b), Gilbert v. Derwinski, 1 Vet. App. 49 53 (1990). Referral of this claim for a total rating for compensation based on individual unemployability is not warranted. ORDER Service connection for heart disease is denied. Service connection for gastrointestinal disease is denied. An increased evaluation for post-traumatic stress disorder is denied. A total rating for compensation based on individual unemployability is denied. H. N. SCHWARTZ Member, Board of Veterans' Appeals