Citation Nr: 1729083 Decision Date: 07/25/17 Archive Date: 08/04/17 DOCKET NO. 12-21 260 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an evaluation in excess of 40 percent for an undiagnosed condition manifested by flu-like nausea and stomach distress (hereinafter "gastrointestinal disorder"). 2. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with depressive disorder prior to July 1, 2016. 3. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with depressive disorder from July 1, 2016 forward. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Fitzgerald, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1989 to March 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal of February 2010 and April 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In August 2016, during the pendency of the appeal, the RO increased the rating for PTSD with depressive disorder to 50 percent, effective July 1, 2016. This decision constitutes a partial grant of the benefits sought on appeal. The issue therefore remains on appeal and is for consideration by the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). These appeals were processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record, in addition to the Veteran's Virtual VA paperless claims file. FINDINGS OF FACT 1. Symptoms of the Veteran's gastrointestinal disorder are more comparable to severe; associated with constant nausea, vomiting multiple times daily, loose stools several times per week, regular episodes of constipation, periods of stomach cramps, and profuse sweating. 2. The Veteran's PTSD has been characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of mood, difficulty sleeping, irritability, anxiety, depression, avoidance, and difficulty establishing and maintaining effective social relationships, but not by occupational and social impairment with deficiencies in most areas. 3. The Veteran's service-connected disabilities preclude him from securing and following a substantially gainful occupation. CONCLUSION OF LAW 1. The criteria for a disability rating of 60 percent, but not higher, for a gastrointestinal disorder are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7308 (2016). 2. PTSD is no more than 50 percent disabling. 38 U.S.C.A. §§ 1155, 5107, 5110(b) (West 2014); 38 C.F.R. §§ 3.102, 3.400, 4.7, 4.130, Diagnostic Code 9411 (2016). 3. The criteria for entitlement to a TDIU are met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). VA's duty to notify was satisfied by letters in February, May, June, July, and September 2010, and the Veteran acknowledged that he received VCAA notice in March, June, and September 2010 signed responses. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016). Regarding the duty to assist, the record contains the Veteran's service treatment records, VA medical records, VA examination reports, the Veteran's lay statements, and statements from the Veteran's coworker and significant other. No other available evidence has been identified. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See 38 C.F.R. § 3.159 (c)(4). The Veteran underwent VA examinations in August 2010, November 2010, and July 2016. The Board finds that the examinations are adequate because they were based on considerations of the Veteran's prior medical history, examinations, and lay contentions and also describes the disability in sufficient details so that the Board's evaluation of the disability will be a fully informed one. See Barr v. Nicholson, 21 Vet. App.303, 312 (2007). Additionally, neither the Veteran nor his representative identified any shortcomings in fulfilling VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Thus, the Board finds that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA. The claims will be adjudicated based on the evidence of record. II. Ratings Disability ratings are assigned, under a schedule for rating disabilities, based on a comparison of the symptoms found to the criteria in the rating schedule. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2016). When evaluating a mental disorder, the rating agency 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 upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. Where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App.505, 510 (2007); Fenderson v. West, 12 Vet. App.119 (1999). As noted above, the RO determined that the Veteran's PTSD demonstrated a change in severity and impairment on July 1, 2016. The Board, however, does not find any indication that the Veteran's PTSD with depressive disorder has materially changed and as a result staged ratings are not warranted. Descriptive words such as "slight," "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3 (2016). A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App.49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. III. Gastrointestinal Disorder VA regulations provide that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. 38 C.F.R. § 4.113. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. Id. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342 and 7345 to 7348 inclusive will not be combined with each other. A single rating will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Veteran has been service-connected for his gastrointestinal disorder since November 2, 1994, with an evaluation pursuant to hyphenated Diagnostic Code 8873-7308. In April 2010, the Veteran filed a claim requesting an increased rating. The RO assigned the Veteran's gastrointestinal disorder a 40 percent evaluation effective June 18, 2007. Hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27 (2016). The first four numbers reflect the diagnosed disability. The second four numbers after the hyphen identifies the criteria used to evaluate that disability. Diagnostic Code 8873 is used for tracking purposes when rating an undiagnosed illness for a Persian Gulf War veteran by analogy to one of the gastrointestinal diseases found in VA's Rating Schedule. The provisions of 38 C.F.R. § 4.114 , Diagnostic Code 7308, pertain to post-gastrectomy syndrome. According to the criteria set forth in Diagnostic Code 7308, a 40 percent rating is warranted for moderate symptoms; less frequent episodes of epigastric disorders with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss. A 60 percent rating, the maximum under the Diagnostic Code 7308, is warranted for severe symptoms; associated with nausea, sweating, and circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. 38 C.F.R. § 4.114. June 2007 VA treatment records show that the Veteran began experiencing diarrhea in addition to his nausea and vomiting. Between June 2007 and July 2007, the Veteran lost nearly 10 pounds, and continued gradual weight loss through September 2009. In August 2010, the Veteran submitted lay statements from his significant other with whom he shared residence. She stated that she witnessed the Veteran experience constant extreme fatigue and violent nausea and described him as chronically sick. She reported that the Veteran had episodes of vomiting every morning upon waking and experienced continued waves of nausea throughout the entire day. In order to calm or settle the symptoms, the Veteran's significant other said that the Veteran had to stop whatever he was doing and rest. In August 2010, the Veteran's submitted statements relay that his gastrointestinal disorder symptoms were so severe that he was unable to hold employment. He reported that he had been seeking care for his gastrointestinal disorder symptoms since January 1991 and had not experienced any improvement. An August 2010 VA examination described the Veteran's nausea as severe. Diarrhea was reported 2-3 times weekly, as well as abdominal pain with distension. The Veteran reported that he attempted modifying his diet to exclude gluten, but that it did not provide any relief. He also restricted his diet to liquid foods because he retained that form of food better than solid food. In October 2010, the Veteran submitted a lay statement from a previous coworker. The coworker described witnessing the Veteran regularly stop what he was doing and gag. He witnessed the Veteran profusely sweat and experience dizzy spells. The Veteran's coworker also said that the Veteran had to excuse himself and run to the bathroom to vomit on several occasions. The coworker also suggested that he considered the Veteran to be chronically ill. The Veteran was afforded another VA examination in November 2010. The Veteran reported daily severe abdominal pain, on a pain scale of 6-7/10, and that his lower bowels felt inflamed. He was continuing to experience severe nausea and vomiting 3 to 4 times in the morning and 3 to 4 times again throughout the day. The Veteran reported that he usually experienced constipation for 2 to 3 days at a time followed by 2 to 3 days of diarrhea, with some instances of blood in his stool. VA treatment records following his November 2010 examination are consistent with the symptoms above, and document consistent treatment and medication. At a July 2016 VA examination, the Veteran reported that he continues to experience chronic nausea daily. He reported that his nausea is accompanied by sweating, sometimes profusely. Waves of nausea were reported to occur 7 to 10 times every day, typically leading to vomiting. The Veteran described sensations in his abdomen as uncomfortable, but not necessarily painful. The Veteran reported fluctuating about 7 pounds in weight within the last year. At the time of the examination, the Veteran was at the higher end of his general weight measurements. He continued to report regular diarrhea, but was not witnessing blood in his stool. He reported that he was still not given a clear diagnosis on his gastrointestinal disorder. The examiner reported that the treatment plan for the Veteran's gastrointestinal disorder included taking continuous medication. At the time of the examination, the Veteran was prescribed Omeprazole and Ondansetron. Here, the evidence is in equipoise as to whether the Veteran's service-connected gastrointestinal disorder warrants a rating of 60 percent. 38 C.F.R. § 4.114, Diagnostic Code 7308. The maximum rating of 60 percent is warranted for severe postgastrectomy syndrome associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. Id. In this respect, the Veteran has described and his medical records reflect ongoing chronic nausea and vomiting, diarrhea, and profuse sweating. On several occasions, the Veteran's symptoms have been described by VA examiners as severe. Concerning weight loss, while the Veteran's weight has fluctuated during the appeal period, it appears that the Veteran has maintained a consistent weight range and isn't malnourished or anemic. In resolving the benefit of the doubt in favor of the Veteran, the Board finds that the symptoms of the Veteran's disability are more comparable to a severe disability rather than moderate. 38 C.F.R. § 4.6. A rating of 60 percent, but no higher, for his service-connected gastrointestinal disorder, is granted. The Board considered other diagnostic codes, but found no lay or medical evidence of perforated ulcer or peritoneum adhesions to warrant consideration of Diagnostic Code 7301, hypertrophic gastritis with severe hemorrhages or large eroded or ulcerated areas to warrant consideration of Diagnostic Code 7307, or resection of small intestine with severe impairment of health supported by material weight loss under Diagnostic Code 7328. In addition, there is no evidence of an ulcer, marginal, to warrant consideration under Diagnostic Code 7306. The various other diagnostic codes, to include hernia and colitis, have no application in this case as the Veteran is not service-connected for such disabilities. There is no identifiable period that would warrant a rating in excess of 60 percent for a gastrointestinal disorder. Staged ratings are not appropriate during the appellate period. See Fenderson, supra. In light of the above, a preponderance of the evidence is against a rating in excess of 60 percent, and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. IV. PTSD with Depressive Disorder The Veteran's PTSD with depressive disorder is rated under Diagnostic Code 9411, covering PTSD. 38 C.F.R. § 4.130. PTSD is rated using the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short and long term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance or minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives and own occupation or name. Id. When determining the appropriate disability evaluation under the general rating formula, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list. Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability rating under the general rating formula by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Id. at 117-18. The Veteran's PTSD with depressive disorder is currently assigned a 50 percent disability rating after July 1, 2016, and a 30 percent rating prior to that date. The Veteran claims the rating does not accurately depict the severity of his condition. In March and April 2010 VA treatment records, the Veteran reported having difficulty sleeping, but that episodes of sleeplessness occur sporadically and he was able to get back to his regular sleep schedule. The physician reported that the Veteran was alert, oriented and calm. His affect was blunted and his mood was slightly dysphoric. The Veteran denied suicidal or homicidal ideations. His thought appeared logical and goal oriented, and his judgment and insight were within normal limits. Submitted lay statements from the Veteran's significant other in August 2010 describe short term memory impairment. The Veteran attended a VA examination in August 2010. He reported feeling very depressed, being extremely self-critical, sleeplessness, irritation, avoidance, and overreaction to people including his children. The Veteran reported that he recently stopped engaging in activities that he used to enjoy, such as working, hunting, fishing and riding motorcycles with friends. He also stated that he was unable to do any mechanical work around his home. He denied any suicidal or homicidal ideations. The examiner noted that the Veteran had a marked decrease in energy and significant loss of interest. During the interview, the Veteran's speech was clear but rather slow most of the time, and he was cooperative and attentive but also somewhat withdrawn and obviously distressed. The Veteran's remote, recent, and immediate memory all appeared to be intact. The examiner concluded that the Veteran was able to maintain activities of daily living to include personal hygiene, but that there was an occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to signs and symptoms of PTSD but generally satisfactory functioning. 2012 VA treatment records document that the Veteran was depressed, but normal speech, thought process, and content. He was alert, with no suicidal or homicidal ideation and normal memory. December 2013 VA treatment records show that the Veteran reported being depressed and dysphoric. He presented with a restricted affect and noted being hopeless and helpless. The physician reported that the Veteran's thought processes remained normal and he was alert and oriented with no memory problems. No suicidal or homicidal ideations were reported. Several weeks following this appointment, the Veteran's affect was again normal, and his symptoms had returned to baseline, with only occasional hopelessness. 2014 through 2016 VA treatment records reflect consistent symptoms and treatment. At a July 2016 VA examination, the examiner found the Veteran to be attentive, cooperative and responsive, with logical statements and adequate concentration, abstract reasoning and continuity of thought. The Veteran's memory was found to be intact. The Veteran has been married since 2011 and reported a solid relationship with his children and his spouse. The examiner found the Veteran to have some problems with being distracted. The examiner concluded that the Veteran had occupational and social impairment with reduced reliability and productivity due to anxiety, chronic sleep impairment, depressed mood, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Continuous medication was required. The Veteran submitted a statement in July 2016 in which he reported that his PTSD and depressive disorder symptoms, including forgetfulness and anxiety in crowds, were an issue with multiple employers. No other relevant evidence discussing the Veteran's mental disorders has been introduced since July 2016. The AOJ assigned a staged rating for the Veteran's PTSD for depressive disorder based on the July 2016 VA examination in which the examiner concluded that the Veteran's disability caused occupational and social impairment with reduced reliability and productivity. However, the Board reviewed all manifestations during the appellate period and finds that there has been no significant change, as VA examinations and treatment records show similar symptoms and treatment. Staged ratings are therefore inappropriate and a uniform rating should be applied for the entire appellate period. The Veteran's primary PTSD and depressive disorder symptoms include feelings of depression, being self-critical, sleeplessness, irritation and overreaction. During the VA examinations and treatment visits the Veteran exhibited good concentration and comprehension, no memory impairment, the ability to solve simple problems, and logical and coherent thought. The Veteran also has consistently denied hallucinations, inappropriate behavior, obsessive or ritualistic behavior, panic attacks, or homicidal or suicidal ideation. The Veteran did not exhibit symptoms such as panic attacks more than once a week; circumstantial, circumlocutory, or stereotyped speech; difficulty in understanding complex commands; impaired judgment; or impaired abstract thinking; and the Veteran's thought processes and speech were coherent, logical, and intact. In regards to the Veteran's occupational functioning, he has reported problems with maintaining employment because of his PTSD symptoms, including irritability and overreaction. As to the Veteran's social functioning, he has reported a great married life, and a very good relationship with his two children. Based on the lay and medical evidence, the preponderance of the evidence is against a finding that a rating in excess of 50 percent for PTSD with depressive disorder is warranted. The July 2016 VA examiner concluded that the Veteran has occupational and social impairment with reduced reliability and productivity. Although slow, the Veteran's speech was intelligible 100 percent of the time. His responses to questions were appropriate in length and level of detail. The Veteran was well groomed and able to function independently, appropriately, and effectively. Although the Veteran has significant symptoms associated with his mental disorders, these symptoms do not cause deficiencies in most areas. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (General Rating Formula for Mental Disorders, 70 percent). The Veteran does not exhibit suicidal ideation, obsessional rituals, near continuous panic or depression, significantly impaired speech, impaired impulse control, neglect of hygiene, or an inability to maintain relationships, and therefore a higher evaluation of 70 percent is not warranted. Therefore, the Board finds that the record reflects the Veteran's symptomatology overall largely correlates with a disability rating of no more than 50 percent. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). VI. TDIU 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 (2016). 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 (2016). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the Veteran is 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, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). To meet the requirement of "one 60 percent disability" or "one 40 percent disability," the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. In this case, the Veteran meets the threshold requirements for a TDIU. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2016). From August 2005 to January 2010, the Veteran held four different jobs with four different employers. In lay statements, he asserts that his PTSD and depression symptoms caused him to have difficulty interacting with people at work, and led to regular job changes. The Veteran was awarded Social Security Administration (SSA) disability benefits in July 2010. SSA medical reports consist mainly of the Veteran's VA treatment records. The primary diagnosis given on an October 2010 disability determination document is "other and unspecific arthropathies." An August 2010 VA examination for PTSD concluded that employment would be impacted due to psychological issues as indicated by difficultly getting along with coworkers and frequent changes in jobs. As discussed above, the Veteran submitted a lay statement from a previous coworker in October 2010. The coworker described the Veteran as always sick and in pain. The coworker described an incident in which the Veteran was so ill he vomited on to his work equipment. He also stated that the Veteran would attempt to make up for time lost due to illness and work on days he was not scheduled. The coworker conveyed that the Veteran worked while experiencing pain and nausea because he wanted to keep his job. The coworker also reported that the Veteran was asked by his employer to go on short-term disability due to episodes of vomiting. A November 2010 VA examination report for gastrointestinal disorder concluded that the Veteran's daily living was affected. The examiner stated that he did not think the Veteran should obtain employment until a definitive diagnosis was made by the gastroenterology department because of the Veteran's persistent nausea and vomiting, as well as non-service connect arthralgia's. A July 2016 VA examination report stated that the Veteran would have a difficult time remaining alert during a full work day, sustaining modest or heavy work for more than a few hours at a time, and traveling for work or traveling more than 15 minutes to and from work. The examiner concluded that the Veteran may be expected to miss about 75 percent of a full work day due to day-long symptoms and miss half a day on a regular basis due to symptoms that cause the Veteran to report to work late or leave work early. The examiner went on to conclude that the Veteran would best be suited to perform desk work on an "at liberty" basis, meaning that he could work when he felt physically up to it and not work when he was not physically up to it. The examiner reviewed the medical file for the Veteran and was unable to locate a more specific diagnosis for the Veteran's gastrointestinal disorder. The Veteran submitted a statement in July 2016 in which he described attending a work meeting and experiencing nausea. He attempted to make it to the restroom, but did not make it in time and vomited in the nearby trashcan. Following the incident, he was asked by his employer to go on short term disability, which eventually led to his termination. The Veteran also stated that the symptoms of his PTSD were problematic for multiple employers. Considering the evidence of record, the Board finds that the evidence demonstrates the Veteran is unable to obtain or maintain substantially gainful employment. As such, entitlement to TDIU is warranted. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017)(confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record); see also Yancy v. McDonald, 27 Vet. App 484 (2016). ORDER Entitlement to a 60 percent rating, but no higher, for gastrointestinal disorder, is granted. Entitlement to an intitial rating of 50 percent, but no higher, prior to July 1, 2016, for PTSD with depressive disorder is granted. Entitlement to an initial rating in excess of 50 percent for PTSD with depressive disorder, is denied. Entitlement to TDIU is granted. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs