Citation Nr: 1337324 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 08-03 261 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent prior to December 15, 2011 and in excess of 70 percent as of December 15, 2011 for service-connected posttraumatic stress disorder (PTSD) (originally granted as an anxiety disorder). 2. Entitlement to a total disability rating due to individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD B. Berry, Counsel INTRODUCTION The Veteran served on active duty from August 1961 to June 1968. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in June 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. These issues were previously before the Board in November 2011 and were remanded for further development. They have now returned to the Board for further appellate consideration. The issues of entitlement to service connection for hypertension and type II diabetes have been raised the Veteran's representative in the October 2013 Written Brief Presentation, but it has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The evidence of record shows that the Veteran's service-connected PTSD is manifested by deficiencies in most areas of social functioning and occupational functioning throughout the entire appeal period including moderate to severe affect on his ability to function appropriately and effectively, hypervigilence, impaired impulse control, difficulty adapting to stressful circumstances and depression, trust issues and emotional distance from other to include immediate family; the Veteran was assigned a GAF score that ranged from 50 to 59. 2. The Veteran is currently service connected for PTSD, rated as 70 percent disabling; tinnitus, rated as 10 percent disabling; and bilateral hearing loss rated as noncompensable. 3. The evidence of record shows that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a 70 percent disability rating, but not greater, for service-connected PTSD have been met prior to December 15, 2011. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for a disability rating in excess of 70 percent for service-connected PTSD have not been met or approximated as of December 15, 2011. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a TDIU have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 3.341, 4.1, 4.3, 4.15, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance The United States Department of Veterans Affairs (VA) has a duty to notify and assist a claimant in developing a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). With respect to the claim of entitlement to a TDIU, the Board is granting in full the benefits sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. Regarding the Veteran's increased rating claim for PTSD (originally granted as an anxiety disorder), the Veteran is appealing the initial disability rating assignment. The June 2007 rating decision granted the Veteran's service connection claim and therefore, such claim is now substantiated. His filing of a notice of disagreement as to the initial rating assigned in the June 2007 decision does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3). Rather, the Veteran's appeal as to the initial rating assignment triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. Under 38 U.S.C.A. § 7105(d), upon receipt of a notice of disagreement in response to a decision on a claim, the agency of original jurisdiction must take development or review action it deems proper under applicable regulations and issue a statement of the case if the action does not resolve the disagreement either by grant of the benefits sought or withdrawal of the notice of disagreement. If VA receives a notice of disagreement in response to notice of its decision on a claim that raises a new issue, section 7105(d) requires VA to take proper action and issue a statement of the case if the disagreement is not resolved; however, section 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly raised issue. See VAOPGCPREC 8-03 (December 22, 2003); 69 Fed. Reg. 25180 (2004); 38 C.F.R. § 3.159(b)(3) (2013). As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here. The January 2008 statement of the case, under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic codes for rating mental disorders, and included a description of the rating formulas for all possible schedular ratings under this diagnostic code. Therefore, the Veteran was informed of what was needed not only to achieve the next-higher schedular ratings, but also to obtain all schedular ratings above the initial evaluation that the RO assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disability on appeal. With respect to VA's duty to assist, the Board finds that VA has fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's service treatment records, VA examination reports dated in May 2007, September 2008, January 2009, September 2009 and December 2011 and lay statements from the Veteran. The VA examination reports reflect that the examiners obtained an oral history from the Veteran of his mental health disorders and evaluated the Veteran. The examiners documented in detail the claimed and observed symptoms and the effect those symptoms have on his daily life and employment. The May 2007, September 2008, September 2009 and December 2011 VA examiners reviewed the claims file as part of the examination. However, the January 2009 examiner did not review the claims file. When analyzing claims for an increased disability rating, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Furthermore, the Veteran has not asserted and the claims file does not show that evidence in the claims file would have affected the observations of the examiner. See Mariano v. Principi, 17 Vet. App. 305, 3011-12 (2003) (when reviewing the claims file would not affect the observations of an examiner, the failure to review it does not prejudice the claimant). The examiner was aware of the pertinent history of the Veteran's mental disorder based on the Veteran's statements during the examination, as well as, reviewing the Veteran's VA treatment records. Accordingly, the VA examinations are adequate for rating purposes. This issue was previously remanded in November 2011 to provide the Veteran with another VA examination to determine the current severity of the Veteran's service-connected PTSD to include how it effects employment. The claims file contains a VA examination report dated in December 2011 that documents the Veteran's symptoms of PTSD to include any effects on employment. Accordingly, the Board finds that there has been substantial compliance with the December 2011 remand directive. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Based on the foregoing, the record presents no basis for further development to create any additional evidence to be considered in connection with the issue currently under consideration. Under these circumstances, the Board finds that the Veteran is not prejudiced by appellate consideration of the claim on appeal at this juncture, without directing or accomplishing any additional notification and/or development action. II. Criteria and Analysis Increased Rating for PTSD Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Where 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2013). When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C.A. § 5107(b). In general, when an increase in the disability rating 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). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (2013). The Veteran's service-connected PTSD is currently evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. PTSD is rated pursuant to the General Rating Formula for Mental Disorders. Id. Under the General Rating Formula for Mental Disorders, a 70 percent rating is prescribed for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is prescribed for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the Veteran's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In determining whether the Veteran meets the criteria for a 70 percent rating, the Board must consider whether the Veteran has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, or mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). The Global Assessment of Functioning (GAF) Scale is used to report the clinician's judgment of the individual's overall level of functioning. The GAF Scale is to be rated with respect only to psychological, social and occupational functioning. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994 (DSM-IV), at 44. GAF scores range from 1-100 with the higher numbers representing higher levels of functioning. A GAF score ranging between 41 and 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, occasional panic attacks) or serious impairment in social, occupation or school functioning (e.g., no friends, unable to keep a job). A GAF score between 51 and 60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupation, or school functioning (e.g., few friends, conflicts with peers or co-workers). During the appeal the RO increased the disability rating of the Veteran's service-connected PTSD from 50 percent to 70 percent effective December 15, 2011. The medical evidence of record consists of VA treatment records and, VA examination reports dated in May 2007, September 2008, September 2009 and December 2011. Furthermore, the Veteran provided additional information about his PTSD in written lay statements. The Board finds that this evidence, the most pertinent of which is summarized below, shows that the Veteran's condition as a whole more closely approximates the criteria for a 70 percent disability rating during the entire appeal period. In this regard, the evidence of record shows that the Veteran's PTSD more closely approximates deficiencies in most areas of social functioning and occupational functioning prior to December 15, 2011. Specifically, the evidence of record shows the Veteran's PTSD has a moderate to severe affect on his ability to function appropriately and effectively. The Veteran has difficulty falling and staying asleep. See January 2008 VA treatment record and VA examinations dated in May 2007, September 2008 VA examination and January 2009. He explained in a January 2008 VA treatment record that he experiences initial and mid insomnia and he reawakes three to four times a night. He also reported frequent flashbacks of his military experience, particularly, witnessing the incident when a man walked into a plane propeller while the Veteran was working on the flight deck. The Veteran has ongoing symptoms of reliving his traumatic experience, recurrent, intrusive, distressing recollections and recurrent dreams. He feels anxious when he talks about his military experience and therefore, he talks about it rarely. The Veteran's inclination to not discuss his military experiences was noted by the clinician in the January 2008 VA treatment record and the September 2009 VA examiner. The evidence also reveals that the Veteran avoids thoughts, feelings and conversations associated with military trauma. The medical evidence of record indicates that the Veteran has hypervigilence, impaired impulse control, difficulty adapting to stressful circumstances and depression. The Veteran reported feeling jumpy and nervous in the May 2007 VA examination. He was irritable and anxious, although he did not reported any physical aggression. The evidence also reflects that prior to December 15, 2011 the Veteran was hypervigilent and had an exaggerated startle response. See January 2008 and February 2008 VA treatment records, January 2009 VA examination. The nurse practitioner in February 2008 noted that the Veteran was very suspicious and guarded. He tends to watch people and his environment constantly. The evidence of record prior to December 15, 2011 also reveals that the Veteran exhibits some inability to establish and maintain effective relationships. He has been married to the same woman for over 40 years and he has two adult children. The Veteran indicated that he has very limited friends and he cannot spend long periods of time even with friends. He is not comfortable being around other people and he does not trust others. The Veteran reported in the September 2008 VA examination that he tried to stay as far away from people as possible, even when he was working. He did not socialize with the other employees. He also indicated that he was emotionally distant from others to include his immediate family. With respect to employment, the Veteran retired in 1999 after working for 31 years at a paper company. The company was bought out so he decided to retire. He owned a bar from approximately 1999 to 2006. He is not currently working. The Veteran reported in a January 2009 VA examination that he sold the bar, because he could no longer "take it anymore" as there was too much noise and the "people drove him nuts." The record indicates that his wife also put pressure on him to sell because it was having a negative emotional impact on him. The Board finds that the Veteran does not meet the requirements for a 100 percent disability rating for his service-connected PTSD at any time during the appeal period. Specifically, the evidence of record is negative for characteristics such as gross impairment in thought processes or communication; grossly inappropriate behavior; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The evidence of record shows that the Veteran's speech was normal in tone, rhythm and rate. See January 2008 VA treatment record and September 2009 VA examination. A January 2009 VA examination indicates that the Veteran will mispronounce words or mix up similar words (i.e., conservation and conversation) that has worsened gradually over the last ten to fifteen years. However, the preponderance of the evidence shows that his thought process was linear and goal directed and thought associations were intact throughout the appeal. See VA examinations dated in May 2007, September 2008, January 2009 and December 2011, January 2008 VA treatment record. The evidence of record shows that the Veteran's behavior was appropriate. The Veteran was oriented to time and place throughout the appeal period. See VA treatment records dated in January 2008, February 2008, May 2010, November 2010, June 2011 and July 2011 and VA examination report dated in September 2009. Although the Veteran has mild memory problems, such as forgetting names, directions or recent events, there is no evidence to suggest that the Veteran has memory loss with respect to names of close relative, own occupation or own name. The evidence of record also does not indicate that the Veteran is in persistent danger of hurting himself or others. The Veteran has indicated that he has suicidal and homicidal ideation. However, the evidence of record consistently shows that the Veteran does not have any intent or plan to act on these thoughts. The evidence of record also does not reveal that the Veteran has intermittent inability to perform activities of daily living. In this regard, the Veteran has consistently appeared well groomed and appropriately dressed. However, the Veteran indicated in the September 2009 and December 2011 VA examinations that his wife picks out his clothes for him to wear and if it was up to him he would wear the same clothes every day and shower only once a week, because he does not care at all about how he looks. The September 2009 VA examiner noted that the Veteran believed that he was able to maintain minimal personal hygiene and other activities of daily living. Furthermore, the evidence shows that the Veteran's symptoms do not result in total occupational and social impairment due to his PTSD. In this regard, the Veteran has been with his wife for over forty years. Although he prefers to be alone, he will visit with friends. He does not like being in crowds or around other people. The Veteran also has trust issues. With respect to employment, the Veteran last worked in 2006 and he has little motivation to look for another job. The VA examiner in December 2011 determined that the Veteran's symptoms of PTSD did not result in total occupational impairment and that he would likely be able to work in a position that allowed for flexible hours, limited social demands and not pressed for productivity. She noted that it was more likely than not that the Veteran would be able to secure full-time gainful employment. Although the evidence indicates the Veteran's PTSD has resulted in his current unemployment and caused moderately-severe impairment in social functioning, in reviewing the entire evidence of record, his symptoms do not more closely approximate total occupational and social impairment due to PTSD. Based on the evidence and analysis discussed above, the criteria for a 100 percent rating have not been met or approximated. The Veteran's GAF score ranged from 50 to 59 throughout the entire claims period. This range in GAF score reveals moderate to serous symptoms with moderate to serious difficulty in social and occupational activities. Thus, the Veteran's GAF score is consistent with the Veteran's overall disability picture including symptoms reported at the VA examination and discussed in the lay evidence indicating that the Veteran's disability picture more closely approximates the current 70 percent disability rating. The Board has considered whether any staged ratings are appropriate. The competent evidence of record shows that the Veteran's PTSD symptoms have not fluctuated materially as to warrant a 100 percent rating at any time during the course of this appeal. As such, a staged rating is not warranted. According to VA regulation, in exceptional cases where schedular ratings are found to be inadequate, the RO may refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2013). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and it is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the evidence does not show such an exceptional disability picture that the available schedular evaluation for service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in the rating schedule for a mental disorder shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. The Board notes that the record indicates the Veteran is unemployed at least in part due to his PTSD symptoms; however, this is contemplated in the assignment of the 70 percent disability rating. In this case the Board finds that the evidence of record shows that the Veteran's PTSD symptoms have not caused marked interference with employment that has not already been considered in the Veteran's current disability rating. Furthermore, the medical record does not show that the Veteran's PTSD has necessitated frequent periods of hospitalization or otherwise rendered impracticable the regular schedular standards for rating such disability. Under these circumstances, and in the absence of factors suggestive of an unusual disability picture, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. TDIU The Veteran contends that his service-connected PTSD results in total unemployability. Total disability will be considered to exist 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 (2013). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341 (2013). In evaluating total disability, full consideration must be given 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 effects of combinations of disability. 38 C.F.R. § 4.15 (2013). If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he or she has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a) (2013). For the purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. It is provided further that the existence or degree of non-service connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the Veteran unemployable. Marginal employment shall not be considered substantially gainful employment. For purposes of 38 C.F.R. § 4.16, marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). The Board notes that the Veteran is service-connected for PTSD, rated as 70 percent disabling; tinnitus, rated as 10 percent disabling; and bilateral hearing loss rated as noncompensable. As the Veteran's PTSD is rated as 70 percent disabling, the schedular criteria for consideration of a total rating under the provisions of 38 C.F.R. § 4.16(a) are met. Nonetheless, the Board must also determine whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Based on the evidence of record, the Board finds that the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. In order to establish an inability to maintain a substantially gainful occupation, as required for a TDIU award pursuant to 38 C.F.R. § 3.340(a), a veteran is not required to submit proof that he is 100 percent unemployable. See Roberson v. Principi, 251 F.3d 1378, 1385 (2001). Instead, the regulations contemplate more flexibility in the employability determination. Id. The evidence shows that the Veteran's service-connected PTSD makes employment in any type of position extremely difficult. The Veteran last worked in 2006. See June 2007 VA examination. He sold the bar he owned in 2006 at least in part due to his PTSD symptoms as he did not like being around crowds and he would get into arguments with his customers. The December 2011 VA examiner noted that the Veteran's problems with interacting with others, irritability, poor concentration and follow through and alcoholism (which the examiner noted was secondary to his PTSD) influenced the Veteran's decision to sell the business. Furthermore, his wife pressured the Veteran into selling the bar due to his increased drinking and decreased mental health. The examiner also determined that the Veteran's depressed mood, lack of interest and lack of motivation would make it difficult for the Veteran to have the ambition to do what it takes to look and find another position. She asserted that he would be able to work in a position that allowed for flexible hours to account for chronic sleep and motivation and interest problems, limited social demands and not pressed for productivity. The examiner explained that at this time, the Veteran's motivation appears minimal resulting in less likelihood of employment. The Board concludes that the Veteran's symptoms of PTSD and work limitations as discussed by the December 2011 VA examiner would make it very unlikely that the Veteran would be able to find and retain gainful employment that would accommodate his limitations due to PTSD. Based on the foregoing, the overall evidence of record suggests the Veteran would have difficulty with any occupation due to his severe PTSD. Therefore, the Board concludes the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disability. Resolving any reasonable doubt in favor of the Veteran, the Board finds that entitlement to a TDIU is warranted. ORDER Entitlement to an initial disability rating of 70 percent, but not greater, prior to December 15, 2011 for service-connected posttraumatic stress disorder is granted. Entitlement to an initial disability rating in excess of 70 percent as of December 15, 2011 for service-connected posttraumatic stress disorder is denied. Entitlement to a TDIU is granted. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs