Citation Nr: 1733167 Decision Date: 08/15/17 Archive Date: 08/23/17 DOCKET NO. 10-31 859 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD) prior to August 16, 2011. 2. Entitlement to an initial rating in excess of 70 percent for service-connected PTSD from August 16, 2011. 3. Entitlement to a total disability rating based upon individual unemployability (TDIU) prior to August 16, 2011. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran served on active duty from May 1981 to August 1981, November 1990 to May 1991, and from February 2003 to December 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee that granted service connection for PTSD and assigned an initial noncompensable rating. In a May 2010 RO decision, the initial rating for PTSD was increased to 30 percent. Then in a March 2017 decision, the Appeals Management Center (AMC) increased the initial rating for PTSD to 70 percent and granted TDIU with both awards effective August 16, 2011. As higher ratings or earlier effective dates are available, the claims remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board has recharacterized the issues to reflect the staged ratings and the issue of TDIU in connection with the original July 29, 2009 claim for service connection for PTSD. Rice v. Shinseki, 22 Vet. App. 447 (2009). In July 2012, the Veteran testified before a Veterans Law Judge (VLJ) who has retired. A transcript of the hearing is associated with the claims file. The Veteran was given an opportunity to elect to have another hearing before a different VLJ, but he declined to have another hearing. See August 2016 statement from the Veteran. In October 2013 and December 2016, the Board remanded this appeal for additional evidentiary development. The requested development has been substantially completed, and the case is ready for appellate review. FINDINGS OF FACT 1. Throughout the appeal, the symptoms and overall impairment caused by the Veteran's PTSD have more nearly approximated occupational and social impairment with deficiencies in most areas, but it has not more nearly approximated total occupational and social impairment. 2. Throughout the entire appeal period, the Veteran's service connected disabilities render him unable to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to August 16, 2011, with reasonable doubt resolved in favor of the Veteran, the criteria for an initial rating of 70 percent, but no higher, for PTSD, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 3.400, 4.1, 4.2, 4.3, 4.7, 4.130, DC 9411 (2016). 2. Throughout the entire appeal period, the criteria for a total rating for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 3.400, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2016). 3. Prior to August 16, 2011, with reasonable doubt resolved in favor of the Veteran, the criteria for a TDIU are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.400, 4.16 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Regarding the TDIU claim, the instant decision results in a complete grant of the benefit sought. Discussion of VA's duties to notify and assist is needed for this issue. As to the higher initial rating claim, the Veteran was appropriately notified about the information and evidence needed to substantiate the claim in an August 2009 letter. The Veteran does not assert any prejudice from any notification deficiency and none has been identified by the Board. The duty to notify is satisfied. In addition, VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claims, and affording him multiple VA examinations. As indicated by the discussion below, these examinations are adequate because they were based on consideration of the Veteran's prior medical history and described his PTSD in sufficient detail to allow the Board to make a fully informed evaluation. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). There is no evidence that additional records have yet to be requested, or that additional examinations are in order. In July 2012, the Veteran testified at a hearing before a VLJ who has since retired. He was afforded an opportunity for another hearing, but declined in August 2016. The provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the hearing, the retired VLJ identified the issues on appeal and inquired as to the PTSD symptoms and employment status. Neither the Veteran, nor his representative, has asserted that VA failed to comply with these duties; they have not identified any prejudice in the conduct of the Board hearing. The Board, therefore, concludes that it has fulfilled its duty under Bryant. The Board will therefore proceed to the merits of the appeal. II. Increased rating for PTSD Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). As shown below, an initial, uniform 70 percent is warranted for PTSD in this particular case. The Veteran's PTSD is currently evaluated as 30 percent disabling prior to August 16, 2011 and 70 percent disabling thereafter under 38 C.F.R. § 4.130, DC 9411. All acquired psychiatric disorders, with the exception of eating disorders, are evaluated under the General Rating Formula for Mental Disorders. Under the general rating formula, a 30 percent evaluation is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks, (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted 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 an 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. A total schedular rating of 100 percent is warranted 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. 38 C.F.R. § 4.130, DC 9411. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the veteran's symptoms, but it must also make findings as to how those symptoms impact the veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because 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, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, 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 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Global Assessment of Functioning (GAF) scale reflects psychological, social, and occupational functioning of a hypothetical continuum of mental health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV)). A GAF score between 61-70 contemplates some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. A score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). A score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). In his July 2009 claim, the Veteran reported that he was being treated for PTSD at the Marion, Illinois VA Medical Center (VAMC). He started treatment in March 2009. In an attached statement, he reported that he experienced poor sleep, nightmares, flashbacks, anxiety, startleness, impaired concentration, irritability and avoidant behaviors. July 2009 VA Mental Health (MH) records show that the Veteran complained about nightmares and intrusive thoughts about military stressors. The Social Worker listed an assessment of emotional distress with possible PTSD and a GAF of 55. August 2009 VA MH records show diagnoses of depressive disorder and PTSD. The Veteran complained about marital problems. The Social Worker assessed depressive disorder and rule out PTSD with a GAF of 50. VA MH records from September 2009 include references to passive suicide ideation, but the clinician maintained an assessment of low risk for self-harm. November 2009 VA MH records indicate that the Veteran adamantly denied any suicide ideation. December 2009 VA MH records include a GAF assessment of 52. The clinician noted that quantitative testing revealed a score suggestive of severe depression. Notably, the Veteran expressed interest in increasing the amount of antidepressants and starting individual therapy. In December 2009, the Veteran was afforded a VA examination. He reported being married for the last 26 years. He described a good relationship with his children. However, he acknowledged prior difficulties and that he had only recently reconnected with his children from his first marriage. He lived with his wife in a home that they owned. He detailed several military stressors. He reported working for 32 years in light manufacturing. Although the company remained in business, the plant he worked for had closed. The examiner noted a history for depression with minimal benefit from antidepressant medication. Currently, the Veteran was socially isolated, but described himself as having been much more outgoing in the past. Mental status examination (MSE) showed the Veteran to be fully oriented and somber during the interview. Speech was low in rate and tone with tremulousness. The Veteran described his mood as depressed. Affect was moderately restricted and tense. Mild psychomotor agitation was observed. The examiner commented that the Veteran shifted uncomfortably in his chair and wrung his hands throughout the interview. The examiner did not observe a thought disorder or any indication of psychosis. The Veteran described having early waking type insomnia. The examiner assessed judgment and personal insight as fair to poor. Impulse control was poor. The Veteran denied suicidal or homicidal ideation. The examiner assessed low-average cognitive function. The Veteran further detailed current insomnia, irritability and diminished appetite. He had social problems and isolation. He avoided war news and children's' activities. The examiner commented that objectively he observed anxiousness and tension from the Veteran and mildly impaired attention and concentration. As for daily activities, the Veteran had problems from poor sleep and shopping with crowds. The examiner assessed the Veteran as credible. He stated that PTSD was the primary diagnosis and additional problems were related to adjustment disorders. He assessed a moderate level of impairment. He listed the diagnoses as PTSD and adjustment disorder with depressed mood. A GAF of 65 was listed. In January 2010, the Veteran had his initial consultation for individual therapy. As relevant, the Veteran reported residing with his longtime spouse and a disabled adult daughter. He reported having impaired sleep and appetite. The clinician also noted startle reflex, depressed mood, flashbacks, hypervigilance and occasional forgetfulness. The clinician assessed depression, anxiety, PTSD and rule out obsessive compulsive disorder (OCD). A GAF of 52 was listed. A subsequent January 2010 VA MH note included reports of continued low mood and associated poor appetite with limited improvement from antidepressants. The Veteran continued to have difficulty sleeping, intrusive thoughts, marital problems and passive suicide ideation. The clinician assessed major depression and PTSD by history. A GAF of 50 was listed. March 2010 VA MH records reflect PTSD symptoms substantially similar to those recorded in January 2010. July 2010 VA MH records show that the Veteran's mood had improved. He stated that most of his fellow service members had returned home and the news had alleviated much stress. He also reported improved communication with his wife. The clinician reiterated the previous diagnoses and raised the GAF to 55. August 2010 VA MH records reflect that the Veteran had increased irritability and depression associated with gout. The clinician referenced an exacerbation of PTSD symptoms and noted some rage and impulsivity. She listed an impression of PTSD major depressive disorder (MDD), anxiety disorder, bereavement and alcohol abuse. A GAF of 50 was listed. October 2010 VA MH records indicate that the Veteran's mood improved with resolution of his pain issues. His sleep had improved as well with decreased nightmare intensity. The clinician reiterated the prior diagnoses and raised the GAF to 56. December 2010 VA MH records show that the Veteran was stable. The clinician noted the Veteran appeared to be coping well with recent family deaths. The clinician reiterated the prior diagnoses and raised the GAF to 62. March 2011 VA MH records reflect that the Veteran complained about sleep problems and had nightmares about Iraq. He recounted his stressors. He indicated that he enjoyed meeting with friends from his old unit and that his relationship with his wife had improved. The GAF was raised to 55. June 2011 VA MH records indicate that the Veteran's mood had stabilized. However, he continued to have four to five hours of sleep and only fair energy level and appetite. The clinician raised the GAF to 62. In June 2011, the Veteran was afforded a VA PTSD examination. He reported having intrusive thoughts, recurring nightmares and difficulty sleeping with as little as three to four hours some nights. He also reported depression and anxiety. However, his mood would improve around people, but at times his depression led him to isolate. He was currently treated with medication and individual therapy. Both were helpful. He resided with his spouse and described their relationship as fair. He cited their limited activities as a couple. He regularly socialized with his siblings. MSE showed the Veteran to be fully oriented and cooperative. His speech was relevant and coherent. No psychosis or thought disorder was indicated. The examiner commented that the Veteran appeared capable of maintaining personal hygiene and other basic activities of daily living. He indicated the Veteran's memory was intact and concentration was fine. No suicidal or homicidal ideation was suggested. The examiner diagnosed PTSD and depressive disorder. He listed a GAF of 55. He concluded that the Veteran had mild to moderate PTSD symptoms with the symptoms becoming moderate after specific stressors, such as watching a war movie. He did not believe the PTSD symptoms were severe enough to interfere with gainful employment. August 2011 VA MH records include complaints that intrusive thoughts and nightmares increased following a recent a military reunion. The clinician noted a melancholy mood. She encouraged the client to improve his communication skills with his wife. She lowered the GAF to 54. VA MH records from August 16, 2011 to July 6, 2017 indicate that the Veteran continued to have domestic stressors and symptoms of sleep disturbances, depression and irritability. They indicated relatively minor changes in the severity, frequency and duration of established PTSD symptoms without any period of notable improvement or deterioration. At the July 2012 Board hearing, the Veteran reported having anxiety, sleep disturbances, flashbacks, irritability, concentration problems and hypervigilance. He also endorsed passive suicide ideations. He stated that he could not work due to his inability to pass physical examinations. His PTSD symptoms interfered with his social function and caused him to isolate from others. His wife reported that the Veteran had dramatically changed after his deployment. When he returned, he had anhedonia type symptoms leading him to neglect his personal hygiene. He had a labile mood and became upset over nominal matters. She cited a trivial argument over washing dishes. She encouraged him to seek MH treatment. His sister-in-law reiterated his wife's description of the Veteran's symptoms. The Veteran acknowledged that he had developed perfectionist traits during service and had problems readjusting to civilian life. He reported having irritable outbursts and that others had threatened to call the police due to his aggressive behavior. In January 2017, the Veteran was afforded a VA PTSD examination with review of the electronic claims folder. The examiner listed diagnoses of PTSD and major depressive disorder. She stated that the symptoms were inseparable. She assessed the occupational and social impairment due to PTSD symptoms as akin to deficiencies in most areas of function. Currently, the Veteran lived with his wife and disabled adult daughter. He stated that he had marital problems since he returned from overseas service. He cited his pervasive irritability and isolative behaviors. The examiner noted the recent outpatient treatment at a local VA outpatient clinic in Mayfield, Kentucky and that there was no history for inpatient psychiatric treatment. As for current symptoms, the examiner indicated that they appeared more severe and frequent as compared to the last examination. The Veteran continued to have sleep disturbances with trauma-related nightmares and intrusive thoughts on a regular basis. He remained very hypervigilant. He had poor concentration and was easily distracted. He was often in an irritable mood and frequently argued with others. He no longer visited with his siblings as he had in the past. He was upset that his old friends had died of various medical issues and he had not made any new friends. He acknowledged excessive ruminations about death, but denied any suicidal intent or plan. The VA examiner detailed how the Veteran's symptoms satisfied each PTSD criterion. She summarized the PTSD symptoms as follows: depressed mood, anxiety, chronic sleep impairment, mild memory loss, unusual speech patterns, impaired judgment, disturbances of motivation or mood, difficulty in establishing maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. Behavioral observations indicated that cognitive mental status was grossly intact. The examiner noted a constricted affect and dysphoric mood. Thought process and content was circumstantial, but free from delusions and hallucinations. Suicidal and homicidal ideation was denied. However, the examiner noted persistent thoughts of death. She assessed the Veteran's insight and judgment as fair. She commented that the Veteran understood he had a problem and his irritability affected his judgment. She listed the results from three self-reported assessments that indicated moderate range anxiety and very severe PTSD symptoms. She reiterated the PTSD diagnosis with associated depression and that her impressions were made based upon her clinical experience, complete review of the electronic claims folder, clinical interview and direct observation of the Veteran. The Veteran contends an initial rating in excess of 30 percent prior to August 16, 2011 and 70 percent thereafter is warranted for service-connected PTSD. In this case, the Board will apply the reasonable doubt doctrine to find that the frequency, severity and duration of the Veteran's PTSD symptoms more closely approximate deficiencies in occupational and social function throughout the claims period as explained below. 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411. The Veteran's PTSD symptoms have generally consisted of sleep disturbances, flashbacks, hypervigilance, irritability, depression, ruminating thoughts concerning death and avoidant/ isolative behaviors. The VA MH treatment records and VA examination reports from December 2009 and June 2011 are suggestive that the frequency, severity and duration of PTSD symptoms more closely approximated reduced reliability in occupational and social function. However, the reports from the Veteran, his spouse and sister-in-law at the July 2012 Board hearing indicate that the frequency, severity and duration of PTSD symptoms more closely approximate deficiencies in most areas of occupational and social function. The Board considers their reports to be competent and credible. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence submitted on behalf of the Veteran in weighing evidence). The severity of PTSD symptoms described at the hearing suggest that the Veteran had great difficulty interacting with immediate family members and anyone else in a social or occupational setting due to his irritable outbursts or perfectionist behaviors. They also include reports concerning more severe symptoms of suicide ideation and neglect of personal hygiene as part of anhedonia. It is reasonable to infer that the symptoms described at the July 2012 Board hearing had been present throughout the claims period since there is no indication that the symptoms were new or of a recent onset. By considering the VA MH records prior to August 2011 and December 2009 and June 2011 VA examination reports in light of the July 2012 hearing testimonies, the evidence is at least evenly balanced as to whether the frequency, severity and duration of the Veteran's PTSD symptoms more closely approximate deficiencies in occupational and social function prior to August 16, 2011. Id.; 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411. See also Bankhead v. Shulkin, 29 Vet. App. 10 (2017) (the language of the general rating formula indicates that the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas). The Veteran is not, however, entitled to a higher, 100 percent rating for any portion of the appeal period. The VA examination reports and treatment notes show that the Veteran did not experience the following symptoms or their equivalent: 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); memory loss for names of close relatives, own occupation, or own name. Treating clinicians have not identified psychosis type symptoms or other PTSD symptoms of a frequency, severity and duration that is indicative of total occupational and social impairment. The Veteran has been in outpatient treatment during the pendency of the appeal. He remains in a long term relationship despite a period of separation during the pendency of the appeal. These facts indicate that the frequency, severity and duration of the Veteran's PTSD symptoms do not more closely approximate total occupational and social impairment. Id. In sum, the evidence is at least evenly balanced as to whether the Veteran's disability picture most nearly approximates the criteria for a 70 percent rating prior to August 16, 2011, but at no time more nearly approximates a total rating for PTSD. As the reasonable doubt created by this approximate balance in the evidence must be resolved in favor of the Veteran, entitlement to a rating of 70 percent is warranted for the entire claims period. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not otherwise for application. III. Entitlement to TDIU prior to August 16, 2011 VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing and following "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91. The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a). The Board must evaluate whether there are circumstances in the Veteran's case, apart from any nonservice-connected disability and advancing age, which would justify a TDIU due solely to the service-connected disabilities. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); see also Blackburn v. Brown, 5 Vet. App. 375 (1993). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). From July 29, 2009, the effective date of the initial rating for PTSD, the Veteran is now service-connected for PTSD, rated as 70 percent disabling. He is also service-connected for glaucoma, rated as 30 percent disabling prior to May 23, 2011 and 60 percent thereafter; left knee disability, rated as 10 percent disabling prior to March 7, 2011 and 20 percent thereafter; right shoulder disability, gout, hypertension, diabetes and hemorrhoids with each disability rated as 10 percent disabling. He meets the percentage criteria for a TDIU laid out in 38 C.F.R. § 4.16(a) for the entire appeals period. Even so, to grant TDIU it must be found that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Consequently, the Board must determine whether the Veteran's service-connected disabilities combine to preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a Veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disabilities, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. Inability to work due to advancing age may not be considered. 38 C.F.R. §§ 3.341(a), 4.19 (2016). In making its determination, VA considers such factors as the extent of the service-connected disabilities, and employment and educational background. See 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19. As to the Veteran's employment history, he worked for over 30 years in warehouse labor and left this job in 2003. See December 2013 TDIU application (VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability). Then, he served on active duty from 2003 to 2005. He has not been employed since then. He attained a high school education. Id. In this particular case, the Board finds that the Veteran's occupational and educational experience tends to limit him to manual labor. Caluza, 7 Vet. App. at 506. The multiple service-connected disabilities on their face would significantly interfere with the Veteran's usual employment in warehouse labor with service-connected glaucoma alone being particularly disabling for many manual labor jobs. In this regard, on his December 2013 TDIU application, the Veteran identified glaucoma as the reason for his unemployability and at the July 2012 hearing, stated that he was unable to work because he could not pass a physical examination. The Board finds him competent and credible in such a report and considers the report highly suggestive that the service-connected physical disabilities preclude work for which the Veteran would otherwise be qualified for. Caluza, 7 Vet. App. at 506. The Board has also considered the June 2011 VA PTSD examiner's opinion and March 2012 VA TDIU medical opinion indicating that service-connected disabilities would not preclude sedentary work. While the June 2011 VA examiner indicated PTSD alone should not interfere with employment, this opinion is of limited value since it does not consider the additional service-connected disabilities and reports given at the July 2012 hearing indicative of more severe PTSD symptoms. Id.; 38 C.F.R. § 4.130, DC 9411. The March 2012 VA TDIU opinion is also limited in that service-connected PTSD symptoms are not considered. The Board also points out that the Veteran's occupational experience is in manual labor and the March 2012 opinion supports a finding that the service-connected disabilities preclude manual labor. Id. After having reviewed the record and weighed the evidence both in support of and against the claim, the Board finds that the shows that throughout the entire claims period, the multiple service-connected disabilities rendered the Veteran unemployable. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) ("applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner"; "neither the statute nor the relevant regulations require the combined effect [of disabilities] to be assessed by a medical expert"). Entitlement to a TDIU prior to August 16, 2011 is therefore warranted. ORDER Prior to August 16, 2011, an initial rating of 70 percent is granted for service-connected PTSD, subject to controlling regulations governing the payment of monetary awards. An initial rating in excess of 70 percent for service-connected PTSD is denied, subject to controlling regulations governing the payment of monetary awards. Entitlement to a TDIU prior to August 16, 2011 is granted, subject to controlling regulations governing the payment of monetary awards. ____________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs