Citation Nr: 1339358 Decision Date: 12/02/13 Archive Date: 12/13/13 DOCKET NO. 09-37 845 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a seizure disorder, to include as secondary to a service-connected disability. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Jan Dils, Esq. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from July 1981 to July 1984 and from March 2003 to February 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a November 2008 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in Huntington, West Virginia that in relevant part denied service connection for a seizure disorder and also denied entitlement to a TDIU. The Veteran testified before the undersigned Acting Veterans Law Judge in a videoconference hearing from the RO in June 2013. A transcript of his testimony is of record. In conjunction with the hearing he submitted a private vocational specialist opinion with a waiver of initial RO review. Additionally, in October 2013, the Veteran submitted additional medical evidence, also with a waiver of initial RO review; the Board has accepted this additional evidence for inclusion into the record on appeal. See 38 C.F.R. § 20.800 (2013). FINDINGS OF FACT 1. The most probative medical opinion of records states the Veteran has a seizure disorder that is due to or a result of the service-connected anxiety disorder with depression and insomnia. 2. The Veteran's service-connected disabilities render him unable to obtain and maintain gainful employment consistent with his education, training and work experience. CONCLUSIONS OF LAW 1. The criteria for service connection for a seizure disorder as secondary to the service-connected anxiety disorder are met. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2013). 2. The criteria for entitlement to TDIU are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board's decision below grants in full the benefits requested by the Veteran. Therefore, no discussion of VA's duty to notify and assist is necessary. Entitlement to Service Connection Applicable Legal Principles Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Where a veteran served for at least 90 days during a period of war or after January 1, 1947, and epilepsies or other organic disease of the nervous system manifests to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. §§ 3.307, 3.309(a). Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. The first inquiry is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, id. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. 498, 511. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence and Analysis The Veteran was separated from service in February 2004. His first seizure occurred in March 2007, three years later. Treatment records from Thomas Memorial Hospital in March 2007 show the Veteran had a seizure on March 21. The clinical impression was syncopal episode with possible seizure (cardiac versus neurological etiology). After the Veteran was stabilized at Thomas Memorial Hospital he was transferred to the VA hospital. He was noted on admission to have a prior medical history of anxiety disorder. The initial neurological impression was possible epileptic seizure, but neurological diagnostic testing including electroencephalogram (EEG) and magnetic resonance imaging (MRI) revealed no acute process. The neurologist stated that in the setting of mood and anxiety difficulty, pseudo-seizure was possible. Another assessment during this treatment noted that seizure could have been related to medication interaction since it happened after the first therapeutic dose of Tramadol; Tramadol was accordingly discontinued. The Veteran had no further seizures during treatment, and he was discharged from treatment on March 23 and advised to avoid operating heavy machinery and to abide by his state's requirements for motor vehicle operation. Discharge diagnoses were seizure and dysthymic disorder. On March 28, 2007, the Veteran returned to the VA hospital complaining of syncope and numbness in the right lower extremity followed by possible loss of consciousness. Neurological evaluation was again negative. The discharge diagnoses included syncope/possible seizure, stable; and, anxiety/depression, continue medications. The Veteran was placed on the anti-seizure medication Keppra. The Veteran had a VA tilt-table study (cardiology) on April 16, 2007, to rule out syncope. The impression was negative test for syncope, so the clinical impression was that the recent activity had probably been seizure. A VA neurology outpatient note in June 2007 states the Veteran had experienced dizziness after initiation of Keppra, but the side effect had resolved and there had not been another seizure-like event. Current clinical neurological examination was normal. The Veteran's medication was changed from Keppra to Depakote. In August 2007 the Veteran submitted a claim for service connection for seizures as secondary to medications taken for service-connected disabilities, based on the VA treatment note cited above that his seizure had happened after the first therapeutic dose of Tramadol. The Veteran had a VA examination in September 2007, performed by a physician who reviewed the claims file. The examiner noted that no seizure disorder had been formally diagnosed so far. The Veteran complained of clumsiness and weight gain as side effects of the Depakote, but the examiner stated it was difficult to relate those problems to the Depakote alone. The examiner noted the Veteran's subjective complaints in detail, as well as clinical observations. The examiner stated that the Veteran's history did not allow a clear diagnosis of either syncopal episodes or seizure disorder; in the absence of a diagnosis it was not possible to provide an opinion regarding etiology. However, since the second episode had occurred after Tramadol was discontinued, that theory of causation was called into question. If seizures continue in the future, and are clearly diagnosed as seizures, it will be shown to be unlikely that Tramadol had caused the previous seizures but had only precipitated seizures in a person pre-disposed to same. Subsequently in September 2007 the RO issued a rating decision that denied service connection for a seizure disorder secondary to medications for service-connected disabilities. The denial was based on a finding that a seizure disorder had not been diagnosed. The Veteran presented to the VA emergency room (ER) on January 4, 2008, reporting having suffered another seizure (his third). The Veteran was admitted overnight and was seizure-free during hospitalization, during which the attending neurologist discontinued Depakote in favor of Dilantin. CT scan of the head showed no definite intracranial abnormality. The Veteran was discharged on January 6; the primary discharge diagnosis was seizure and the secondary diagnoses included hypertension, dysthymic disorder, migraine headaches, anxiety and insomnia. The Veteran had a consultation with Dr. Suresh Kumar in February 2008 for second opinion regarding his seizures and tremors. The Veteran endorsed having had three previous seizures in 2007 but denied any seizures since then. Dr. Kumar advised the Veteran to keep to his Dilantin regimen since it seemed to be controlling repetition of seizures. In regard to the Veteran's complaint of depression and lack of sleep, these can basically cause breakthrough seizures, so the Veteran needed to control his depression and get a good night's sleep. The tremors were probably not related to Depakote, and Dr. Kumar stated it might be worthwhile to investigate whether such tremors could be related to service in Southwest Asia, versus a metabolic irregularity. The Veteran presented to the VA neurology clinic in May 2008 for follow-up of suspected seizure disorder. The Veteran reported having had no seizures since January. The previous tremors had decreased markedly since he changed from Depakote to Dilantin. The current clinical neurological assessment was seizures of unknown origin and history of migraine headaches. A VA primary care clinic (PCC) note in May 2008 by Dr. RW notes the Veteran had an occupational history that included four years in service (including Germany, Iraq and Kuwait) with associated immunizations; post-service occupational history was significant for burying cable/operating heavy equipment, followed by press operator at a stamping plant, followed by 13 years as heavy equipment operator and welder for the state highway department. Dr. RW noted the Veteran had welded indoors and outdoors, without a respirator, using acetylene and metal inert gas (MIG). Dr. RW's clinical impression was as follows: (1) seizure disorder on reasonable control with Dilantin; (2) tremor on right, possibly a Dilantin effect; (3) mild incoordination, possibly a Dilantin effect; (4) currently out of work due to lost commercial license; and, (5) rule out maganeses [sic] toxicity or other toxicity related to military assignment. In June 2008 Dr. RW noted the Veteran had three seizures with negative imaging studies since service, and also noted the Veteran had worked after service for the highway department during which he often welded without a respirator. Dr. RW indicated a treatment plan including ambulatory EEG, neurological consult and further research into manganese exposure. The Veteran had a VA Gulf War Guidelines examination in July 2008. The examiner addressed complaints of muscle ache and fatigue but did not address the Veteran's seizure symptoms. The same examiner performed a neurological examination but addressed only headaches. A letter from VA physician GAE dated in July 2008 states as follows: "[the Veteran's] seizure disorder has been aggravated by insomnia, depression and anxiety disorder." The Veteran submitted a Statement in Support of Claim in September 2008 stating he had another seizure in July 2008, as a result of which his Dilantin dosage had been increased. However, VA treatment notes during July 2008 do not document a recent seizure. A letter from VA physician RW dated in December 2008 states as follows: "[the Veteran's] seizure disorder is caused by and/or aggravated by his service-connected anxiety disorder, insomnia and depression." The Veteran had a VA medical examination in July 2009, performed by a physician who reviewed the claims file and noted the Veteran's medical history. The Veteran reported a history of five seizures since March 2007, four of which were prior to starting Dilantin therapy in January 2008, and a fifth seizure in April 2009 that occurred when Dilantin had been stopped. Current detailed neurological examination was normal. The examiner's diagnosis was epilepsy of unknown origin. The examiner stated an opinion that the Veteran's seizures were not caused by his mental health issues in question (generalized anxiety disorder with depression and insomnia). As rationale, the examiner stated the little is known about the specific factors that determine precisely when a seizure will occur. Some patients can identify the situations that appear to lower the threshold for seizure; these can be avoided. Some get seizure when there is sleep deprivation, others relate to alcohol intake and other specific stimuli. If there is an association between stress and seizures, then stress reduction is beneficial. The common trigger factors from literature are tiredness, stress and sleep deprivation; the therapy is to control these factors. In the Veteran's case, he was under good [seizure] control since January 2008 until the medication was stopped by the Veteran on the advice of his physicians (not documented). This suggests that the Veteran's anxiety disorder with depression and insomnia, which is being treated by the VA mental health department), is under good control. The examiner also noted the statement by Dr. RW to the effect that the Veteran's seizure disorder is caused and/or aggravated by his service-connected anxiety disorder, insomnia and depression, but stated this is not true; seizures are not caused by anxiety disorder, insomnia and depression. The Veteran had a VA general medical examination in September 2010, performed by an examiner who reviewed the claims file. The examiner noted the Veteran began having seizures in March 2007 and had seven episodes of grand mal seizures since then. EEG and MRI studies of the brain had been negative for identifying underlying pathology. The Veteran was currently claiming his seizures are related to his service-connected anxiety disorder, and he reported that several seizures had occurred after a bad night of sleep due to sense of dread. The examiner performed a clinical examination and noted observations in detail; neurological examination was grossly normal. The examiner diagnosed seizure disorder and stated an opinion that the grand mal seizures are due to or a result of the service-connected anxiety disorder. As rationale, the examiner stated that while it is true that seizures are not caused by or a result of anxiety/stress/insomnia, it is a well-established fact that seizure episodes are triggered and occur more frequently during periods of emotional stress and insomnia, as it appears to have occurred with this Veteran. This is a fact that is widely documented in the medical literature. The Veteran presented to the VA neurology clinic in May 2011 complaining of another seizure the previous month (April 2011). This was his first reported seizure in 7 months. The neurologist increased the dosage of the Veteran's Tegretol and noted that stress and anxiety are likely to worsen the seizures. A VA neurology note in August 2011 states the Veteran reported having had another seizure the previous month (July 2011); he has been stressed at the time of the event and was not sleeping well. The neurologist stated the seizure appeared to be related to lack of sleep, and that some form of gainful occupation would help the Veteran a bit with the seizures. The Veteran reported another seizure in January 2012. The file was referred to a VA physician in March 2012 to obtain an opinion regarding whether the Veteran's seizure disorder is due to or aggravated by the service-connected anxiety disorder. The reviewer, Dr. WEW, stated that the Veteran's seizure disorder is as likely as not aggravated by the service-connected anxiety and depression. Dr. WEW stated it is conceded that the anxiety and depression preceded the seizure disorder; he stated it is also conceded that anxiety and depression DO NOT (emphasis in original) cause the onset of seizures because, if that were so, everyone on planet Earth would have seizures at some point in their lives. The Veteran also DID NOT (emphasis in original) have seizures prior to the anxiety and depression. The question as to the degree to which the service-connected anxiety disorder causes increased frequency of seizures cannot be answered, because the only way to do so would be to withhold all psychogenic medications and see if the seizures increased in frequency, but it would be medically unethical to perform such an experiment. The Veteran testified before the Board in June 2013 that his first seizure occurred in 2007, and that he has had seizures ever since despite having been prescribed various medications. None of his VA providers had been able to precisely define the cause of the seizures, but the Veteran believes that his seizures are triggered by anxiety and panic attacks. On review of the evidence above, the Board finds at the outset that the Veteran is diagnosed with seizure disorder, although the etiology thereof is unclear. Accordingly, the first element of service connection - medical evidence of a claimed disability - is met. There is no indication of record, and the Veteran does not assert, that his seizure disorder was manifested in service or that it is etiologically related to service. Rather, the Veteran asserts his seizure disorder, which was first manifested in March 2007, is due to or aggravated by his service-connected anxiety disorder. The record contains conflicting medical opinions in regard to whether the service-connected anxiety disorder is the proximate cause of the claimed seizures. The VA examiner in September 2010 articulated an opinion that the Veteran has grand mal seizures that are due to or a result of the service-connected anxiety disorder, which on its face demonstrates proximate causation. In contrast, the VA examiner in July 2009 stated that the Veteran's seizures were not caused by his mental health issues, and the VA reviewer in March 2012 stated that anxiety and depression do not cause seizures but do aggravate the Veteran's seizure disorder. It is the Board's duty to assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995). As true with any piece of evidence, the credibility and weight to be assigned to these opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The VA examiner in September 2010 had access to the factual elements and provided a fully-articulated opinion supported by detailed rationale; the opinion is accordingly probative under the criteria of Nieves-Rodriguez. This opinion is also consistent with the observation of a VA neurologist in March 2007 that in the setting of mood and anxiety difficulty, pseudo-seizure was possible, and with the observation by Dr. Kumar in February 2008 that depression and lack of sleep can cause breakthrough seizures. The VA examiners in July 2009 and in March 2012 also had access to the factual premises and also provided supporting rationale, but the Board finds those rationales to be unconvincing. The VA examiner in July 2009 admitted that "some get seizure when there is sleep deprivation" but stated the Veteran's anxiety disorder appeared to be under good control with medication; this conclusion is inconsistent with the VA mental health records, which show continuing complaints of insomnia (see e.g. the statement of the VA neurologist in August 2011 that the Veteran's most recent seizure appeared to be related to lack of sleep). The VA reviewer in March 2012 stated as rationale that anxiety does not cause seizures because "if that were so, everyone on planet Earth would have seizures at some point in their lives," but this rationale is unsatisfactory because it relies on a generalization that is not specific to this appellant. The Board accordingly finds the opinion of the VA examiner in September 2010 to be the most probative opinion under the criteria of Nieves-Rodriguez. In sum, based on the evidence and analysis above, the Board finds the Veteran has a seizure disorder that is due to or a result of the service-connected anxiety disorder. Accordingly, the criteria for service connection on a secondary basis are met. Benefit of the doubt has been resolved in the Veteran's favor. Entitlement to TDIU Applicable Legal Principles It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate, "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. A TDIU may be assigned, if the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability it is ratable at 60 percent or more, and that if there are two or more such disabilities at least one is ratable at 40 percent or more and the combined rating is 70 percent or more. 38 C.F.R. § 4.16(a). Consideration may be given to the veteran's education, training, and special work experience, but not to his age or to impairment caused by nonservice-connected disabilities. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Evidence and Analysis In its decision above, the Board has found the Veteran's seizure disorder to be service-connected. In addition to seizure disorder, the Veteran is service-connected for the following disabilities: generalized anxiety disorder with depression, rated as 50 percent disabling; migraine headaches, rated as 50 percent disabling; tinnitus, rated as 10 percent disabling; and, hearing loss, rated as noncompensable. His combined evaluation for service-connected disabilities is 80 percent. He accordingly meets the schedular threshold for consideration of a TDIU under 38 C.F.R. § 4.16(a). The Veteran had two seizure-like events in March 2007 that resulted in him being placed on anticonvulsant medication and in being advised by his attending neurologist to refrain for at least a year after resolution of seizures in any activity that could be dangerous with loss of consciousness, especially driving or operating heavy equipment. As recorded in the VA examination in September 2007, the Veteran was concerned about the loss of his job and resultant loss of income, since his job required him to operate heavy equipment and to commute within a 5-county area. The Veteran had a VA psychology evaluation in July 2008, performed by a psychologist who reviewed the claims file. The examiner performed a mental status evaluation (MSE) and noted observations in detail. The examiner stated that records appeared to support the Veteran's contention of unemployability due to seizure disorder, but that from a mental health perspective the Veteran was clearly still employable. The Veteran also had a VA neurological examination in July 2008, performed by a physician who reviewed the claims file. The Veteran complained of severe headaches three times per week, each lasting for hours and generally resolved by sleep overnight. In regard to occupational impairment, the examiner stated that the Veteran should be able to perform light and sedentary work despite the headaches. The file contains a letter from the West Virginia Consolidated Public Retirement Board dated in September 2008. The letter states the Veteran had been placed on disability retirement effective from February 2008 due to his seizure disorder and the medications taken for that disorder, which would present a danger to himself, his co-workers and the general public. The letter also noted the Veteran's commercial driver's license (CDL) had been suspended for three years from the date of the last seizure. The Veteran had a VA mental health evaluation in September 2010, performed by a psychologist who reviewed the claims file. The psychologist diagnosed major depressive disorder (MDD), single episode, and anxiety disorder not otherwise specified (NOS) and assigned a current Global Assessment of Functioning (GAF) of 50. The psychologist deferred to medical examiners in regard to impairment of employability due to physical disabilities, but stated that from a strictly mental health standpoint the Veteran remained employable. The Veteran also had a VA general medical examination in September 2010, performed by an examiner who reviewed the claims file. The examiner noted the Veteran was claiming unemployability due in part to his service-connected headaches but he did not provide an opinion on employability, since the Veteran was currently not employed. Three different VA physicians signed West Virginia Public Employees Retirement System Medical Recertification of Disability in January 2012, certifying that the Veteran was totally and permanently incapacitated from employment and unable to perform any substantial gainful employment. Dr. NAR, a neurologist, cited seizure disorder; Dr. TS cited seizure disorder with unpredictable episodes; and, Dr. ZA, a psychiatrist, cited seizure disorder and anxiety disorder. The file contains a June 2013 report from Vass Vocational Services. The author of the report, a vocational rehabilitation specialist, reviewed the electronic file and interviewed the Veteran. The Veteran reported that due to his general anxiety and depression he isolates himself and avoids others; he also has impaired concentration and memory and tremor during anxiety attacks that make him unable to use his hands. He stated his migraine attacks would occur three times per week and last 1-2 hours at a time, during which he would have to lie down in a quiet dark room. The Veteran's education/training level was high school graduate with no vocational certifications. His employment history was as an equipment operator from 1984-1995 and with the department of highways from 1995-2008; the Veteran's employment skills would not translate to light or sedentary employment. The Veteran also has no clerical or computer skills and no experience as a supervisor. Based on review of the file and on interview of the Veteran, the author stated a conclusion that the Veteran is unable to engage in gainful employment at any exertional level based on the anxiety disorder, which results in chronic fatigue, and also on the migraine headache disorder, which would cause absenteeism to an extent that a normal employer would not tolerate. The Veteran testified before the Board in June 2013 that he had last worked in February 2008, as a heavy equipment operator for a state agency. He stated that he has an average of 3 headaches per week, each lasting 2-4 hours during which he has to be in a cool, dark room. He also has panic attacks at least weekly and avoids crowds. Review of the evidence above demonstrates that the Veteran is rendered unable to obtain and maintain substantially gainful employment by virtue of his service-connected disabilities. In particular, the June 2013 report from Vass Vocational Services provides competent and probative evidence that the Veteran's service-connected disabilities preclude substantially gainful employment in light of the Veteran's education and work history. Based on the evidence and analysis above the Board finds the Veteran's service-connected disabilities render him unable to obtain and maintain gainful employment consistent with his education, training and work experience. Accordingly, the criteria for award of a TDIU are met. Benefit of the doubt on this issue has been resolved in the Veteran's favor. ORDER Service connection for a seizure disorder is granted as secondary to the service-connected generalized anxiety disorder with depression and insomnia. Entitlement to a TDIU is granted. ____________________________________________ M. N. HYLAND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs