Citation Nr: 1751464 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 08-21 901 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) for accrued benefits or substitution purposes. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for accrued benefits or substitution purposes. REPRESENTATION Veteran represented by: Kathy A. Lieberman, Attorney ATTORNEY FOR THE BOARD M. Coyne, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1951 to September 1953. He is the recipient of the Combat Infantryman's Badge. He died in September 2013. The appellant is the Veteran's surviving spouse, and the Agency of Original Jurisdiction (AOJ) has determined that she meets the basic eligibility requirements to substitute for the Veteran pursuant to 38 U.S.C.A. §§ 5121, 5121A (West 2014). This matter originally came before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated June 2007 and March 2008 of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In a June 2011 Board decision, the claims were remanded for further evidentiary development. The VA Appeals Management Center (AMC) continued the previous denials in a January 2012 supplemental statement of the case (SSOC). In an August 2012 decision, the Board granted an initial disability rating of 50 percent, but no higher, for the service-connected PTSD and denied the claim of entitlement to a TDIU. The Veteran appealed the August 2012 decision to the United States Court of Appeals for Veterans Claims (Court). In March 2013, the Court partially vacated the Board's decision and remanded the case to the Board for further consideration pursuant to a February 2013 Joint Motion for Remand (JMR). On October 22, 2013, the Board remanded these claims to the RO for additional development. However, documentation of the Veteran's September 30, 2013 death was subsequently associated with the claims file. Thereafter, the Board vacated the October 2013 decision in an August 2017 decision. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The Veteran's PTSD was manifested by symptoms which most closely approximate occupational and social impairment with deficiencies in most areas. 2. Resolving doubt in favor of the Veteran, and with due consideration for his education and vocational experience, the Veteran's service-connected disability precluded him from securing substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating of 70 percent, but not higher, for the Veteran's service-connected PTSD have been met for accrued benefits or substitution purposes. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.125, 4.130 Diagnostic Code 9411 (2017). 2. The criteria for entitlement to a TDIU have been met for accrued benefits or substitution purposes. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. § 3.102, 3.159, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist VA has met all statutory and regulatory notice provisions set forth in the VCAA. Prior to initial adjudication, a September 2003 letter satisfied the duty to notify provisions with regard to the Veteran's service connection claim for PTSD. In so finding, the Board notes that the Veteran's appeal arises from disagreement with an initial evaluation following the grant of service connection. Once service connection is granted, the claim is substantiated, additional VCAA notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board notes that August 2011 VA examination report was previously found inadequate for adjudicatory purposes in the February 2013 JMR due to its failure to distinguish between the cognitive impairment caused by the Veteran's service-connected PTSD and the cognitive impairment caused by his numerous nonservice-connected conditions. Therefore, to the extent that the Board discusses the August 2011 examination report, it will only rely on it to the extent that it provides evidence of PTSD symptoms in support of the Veteran's claim of entitlement to an increased rating for service-connected PTSD. Therefore, the Board's consideration of this positive evidence will not result in any prejudice to the appellant. As for VA's duty to assist other than as noted above, neither the appellant nor her attorney has raised any other issues with the duty to notify or duty to assist with regard to the Veteran's effective date and PTSD claims. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott, 789 F.3d 1375, to a duty to assist argument). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders, 556 U. S. 396 (2009). II. Entitlement to a Higher Rating for PTSD Where the Veteran challenges the initial rating of a disability for which he has been granted service connection, the Board considers all evidence of severity since the effective date for the award of service connection in date. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, if the positive evidence supporting a claim and the negative evidence indicating a denial of the claim is relatively equal, the Veteran is entitled to the benefit of the doubt. See 38 U.S.C.A. §5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2016). Accordingly, after careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. See id. Disability evaluations are determined by comparing a Veteran's present symptoms with the criteria set forth in the VA's Schedule for Rating Disabilities (rating schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4. 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. As such, the Board must consider all potentially applicable diagnostic codes when rating a Veteran's disability. However, evaluation of the same manifestation of the same disability under various diagnoses, otherwise known as "pyramiding" is to be avoided. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Additionally, consistent with the benefit-of-the-doubt principle, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). Moreover, staged ratings are appropriate for an increased 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)). The Veteran's PTSD is currently evaluated at 50 percent disabling, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, which assigns disability evaluations of 0 percent (noncompensable), 10 percent, 30 percent, 50 percent, 70 percent, and 100 percent. Addressing the disability evaluations relevant to the Veteran's claim, a 50 percent evaluation requires occupational and social impairment "with reduced reliability and productivity due to such symptoms as": (1) flattened affect; (2) circumstantial, circumlocutory, or stereotyped speech; (3) panic attacks more than once a week; (4) difficulty in understanding complex commands; (5) impairment of short-and long-term memory as demonstrated by retention of only highly learned material or forgetting to complete tasks; (6) impaired judgment; (7) impaired abstract thinking; (8) disturbances of motivation and mood; and (9), difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is evidence of occupational and social impairment, "with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as": (1) suicidal ideation; (2) obsessional rituals which interfere with routine activities; (3) speech intermittently illogical, obscure, or irrelevant; (4) near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; (5) impaired impulse control, such as unprovoked irritability with periods of violence; (6) spatial disorientation; (7) neglect of personal appearance and hygiene; (8) difficulty in adapting to stressful circumstances, including work or a work like setting; (9) and inability to establish and maintain effective relationships. Id. Finally, a 100 percent rating is warranted when there is evidence of total occupational and social impairment "due to such symptoms as": (1) gross impairment in thought processes or communication; (2) persistent delusions or hallucinations; (3) grossly inappropriate behavior; (4) persistent danger of hurting self or others; (5) intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; (6) disorientation as to time or place; and (7) memory loss for names of close relatives, own occupation, or own name. Id. The above listed symptoms associated with the 50, 70, and 100 percent ratings are not an exhaustive list of symptoms the Veteran must have or must exhibit; rather they are examples of symptoms that could cause the level of occupational and social impairment contemplated by each rating level. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). As such, the Board need not find all or even some of the listed symptoms to assign any of the above ratings. Id. Instead, the Board must examine the symptoms of the Veteran, determine whether they are of the kind that are enumerated in the disability rating level, and if so, determine whether those symptoms result in the level of occupational and social impairment described by that rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). In doing so the Board may examine the severity, frequency, and duration of the Veteran's symptoms, and determine the similarity they bear to the specific rating levels listed in 38 C.F.R. § 4.130. See id. The Board notes that the current version of 38 C.F.R. § 4.125 (2017), utilizes the Diagnostic and Statistical Manual of Mental Disorders, (5th ed. 2013) (DSM-V) to diagnose and assess mental health disorders. However, previously, including at the time the Veteran's claim was filed and VA examinations procured, VA utilized the Diagnostic and Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM-IV). Accordingly, diagnoses made in VA examinations and VA mental health treatment records often include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score consistent with the DSM-IV. A GAF rating is a scale reflecting the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental-health illness, with higher scores reflecting a greater degree of psychological, social and occupational functioning than lower scores. See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). An examiner's classification of the level of psychiatric impairment through assignment of a GAF score or otherwise, must be considered, but is not in and of itself determinative of the rating level to be assigned to the mental health disorder at issue. VAOPGCPREC 10-95. Therefore, the extent that the Veteran has been assigned a GAF, the Board will consider this evidence. A. Evidence and Analysis A review of the claims file reveals numerous psychiatric treatment records from the 1980s. A letter from Dr. J. C. confirms treatment for nerves beginning in 1981, and records from 1981 onwards show treatment for an emotional condition for which the Veteran was receiving medication, with some improvement of symptoms; the Veteran was noted to have sleep impairment and anxiety, and complained of nightmares and getting very agitated at work. A May 1981 private treatment record notes that the Veteran reported auditory and visual hallucinations which the Veteran described as "revelations." September 1989 private treatment records document nightmares, insomnia, feeling spiritless, and complaints of memory issues. The Veteran complained of becoming disoriented when driving from place to place for work. He also reported marked irritability that was affecting his relationships at work and at home, that he shouted and bit his tongue in his sleep at night, and that he was having suicidal thoughts due to his feelings of worry, but added that he had never done anything against his life due to his Catholic faith. Examination revealed that the Veteran was well groomed, his thought process logical, coherent, and relevant. The Veteran reported that he was making a lot of math mistakes at work and was not being careful when selling his merchandise, and that he was only working two days a week because he did not have enough energy for everyday tasks and woke up in the morning exhausted with no energy. The Veteran was diagnosed with generalized anxiety disorder, remission of alcohol abuse, and rule out convulsive disorder. A September 1989 letter from another private treating physician confirmed that the Veteran had chronic depressive disorder that was disabling. Other treatment records from the late 1980s and early 1990s document a diagnosis of atypical Parkinson's disease. A May 1990 psychiatric evaluation documents decreased psychomotor activity and slow thinking, feeling "good for nothing," memory impairment, and cognitive changes "following anxiety and depression and eroding the Veteran's capability of running by himself a vegetable selling business." The Veteran was unable to complete serial 7s and mathematical calculations. The Veteran reported that he had become suicidal the preceding Christmas and had taken large doses of tranquilizers. He reported feeling fearful, tense, and uncomfortable around others, including family members. The examiner indicated that the Veteran's psychological functioning appeared very deteriorated, and diagnosed the Veteran with major depression and organic brain syndrome which significantly interfered with his ability to work and relate to others in an independent manner, or follow instructions or function under supervision. VA psychiatric records dated in 2003 and 2004 indicate that the Veteran presented with good personal grooming. His mood was described as nervous or depressed with anxious affect. He was relevant, logical, and coherent. He did not appear delusional, suicidal, or homicidal. Cognitive functions appeared grossly intact. He had adequate social judgment with poor insight into his psychiatric condition. A GAF of 60 was assigned. A July 2003 VA treatment record reflects that the Veteran came to an appointment with his wife, who reported that his verbally aggressive behavior had improved since April 2003, when he was reported to be verbally aggressive, irritable, sleep deprived, and to have a low tolerance. A September 2003 VA examination report reflects that the Veteran complained of poor sleep and anxiety. He reported that he stayed home or went out with his wife. His wife managed all of his affairs. He reported that he had to stop working due to not doing business right as he was not able to do his accounting and he was getting lost and disoriented. He complained of forgetting many things and poor memory but reported some improvement with treatment. He complained of variation of his mood with periods of depression. He reported periods of irritability and aggression towards his spouse. On mental status examination, he was adequately groomed. He was alert and oriented to person, place and year. His mood was anxious and slightly depressed. His affect was constricted. His attention, concentration, and memory were fair. His speech was clear and coherent. He was not hallucinating. He was not suicidal or homicidal. His insight and judgment were fair. He exhibited good impulse control. The examiner diagnosed the Veteran with anxiety disorder, not otherwise specified with depressive features, and cognitive disorder due to age, but did not differentiate between depressive symptoms and age related cognitive disorder symptoms. The examiner assigned a GAF of 60. A December 2003 private psychological consultation reflects the Veteran's report that he had recurrent thoughts of service and experienced nightmares. The Veteran reported that he was married with children and went to church but due to limited financial resources he did not engage in any other activity, and that he had multiple medical conditions which prevented him from engaging in activities other than resting and watching television. The Veteran reported that his children visited frequently. On mental status examination, his grooming was appropriate and the Veteran was pleasant, and he did not present signs of receptive or of expressive speech deficits. The Veteran's thought process was goal directed and normal, and he did not present delusional thought trends. The Veteran's mood was within normal range, and his affect was congruent. He seemed to be moved by the traumatic experiences he related and his judgment was unimpaired. The examiner observed that the Veteran presented with nightmares, survivor's guilt, and inability to control his levels of anxiety, depression, and cognitive alterations. The examiner also observed that the Veteran demonstrated impairment of his capacity to utilize his non-verbal intelligence with significant impairment of his verbal memory and construction abilities, and that that he had recurrent periods of mental dullness that by day heightened his cognitive and general adaptive resources. The examiner added that the Veteran's mathematical reasoning abilities were preserved but he experienced difficulties concentrating while performing these operations. The examiner diagnosed PTSD and organic amnesic disorder. The examiner assigned a GAF of 50. A June 2004 private psychiatric evaluation reflects complaints of sleep problems, anxiety, irritability, hypervigilance, and flashbacks about combat in Korea. He Veteran stated that he often felt nervous and depressed with a lack of energy, hopelessness, helplessness, with an inability to concentrate and persistent suicidal thoughts. The Veteran described vivid intrusive recollections of traumatic events of Korea. The Veteran reported that he liked to stay away from people, had close friends, and felt uncomfortable around people. The Veteran also explained that he avoided places and activities that aroused recollections of war. On mental status examination, the Veteran's mood was nervous and his affect was mobile, he denied auditory hallucinations, his thought form was goal oriented, and he denied active suicidal plans but did report recurrent thoughts about suicide. The Veteran's memory was intact both remotely and recently, but immediate memory was impaired due to marked anxiety, and his attention, concentration, and impulse control was impaired. The examiner diagnosed PTSD and major depression with psychosis with a past history of schizophrenia, but the examiner noted that many Veterans had been diagnosed with this prior to 1980 due to recurrent episodes of flashbacks. The examiner also noted that he had early symptoms of cognitive deficits, specifically minimal cognitive impairment. The examiner commented that the Veteran's cognitive impairment was "most likely" caused by the deleterious effect of chronic anxiety. The examiner assigned a GAF of 48, and noted that the Veteran was competent to manage his financial affairs. A September 2006 VA examination report reflects that the Veteran worked as a traveling salesman for 30 years until 1989, but had not worked since then. The Veteran reported that in the last year he had been feeling sad, depressed, with irritability, with loss of interest for the daily activities, with loss of energy, with insomnia, with inability to feel pressure in daily talks, with inability to concentrate, anxiety, restlessness, and tension. He continued to report moderate memory impairment for recent events. On mental status examination, he was appropriately dressed with adequate hygiene, and he was cooperative. The Veteran's thought process was coherent and logical. There was no evidence of delusions and no evidence of hallucinations. The Veteran did not report panic attacks or suicidal ideation at that time. The Veteran's mood was depressed with constricted affect. The Veteran's memory was moderately impaired for recent events and intact for remote events, but his judgment and insight was fair. The examiner opined that the signs and symptoms described above were seriously interfering with the Veteran's employment and social functioning, but that the Veteran was able to maintain basic activities of daily living. The examiner referenced an August 2006 treatment record showed moderate cognitive impairment. The examiner diagnosed major depressive disorder, recurrent, without psychotic features, and assigned a GAF score of 50. VA treatment records dated May 2007 to May 2011 document similar symptoms to those described above including nightmares, sleep issues, anxiety, depression, and conflicts with family members. Additionally, impairment of memory, concentration, and attention were noted. The Veteran's assigned GAF ranged from 40 to 55. At times his judgment and insight were noted to be fair, and at other times they were noted to be poor. The Veteran also intermittently reported visual hallucinations at night, but overall mostly denied visual hallucinations; it is unclear as to whether the visual hallucinations reported were related to nightmares or flashbacks. An August 2008 VA psychiatric treatment record reflects that the Veteran attempted suicide a week prior by overdosing on medications. He was hospitalized for a week and stabilized. The Veteran reported that he had been experiencing multiple conflicts with his family and wife, that he felt his wife was verbally abusive to him, and that he wanted to disappear. Prior to discharge he expressed regret at his actions and denied further suicidal ideation. The Veteran had additional diagnoses of depression, Parkinson's disease vs. vascular dementia, and cognitive memory deficit. However, his speech was coherent and logical and he did not report of evidence delusional thoughts. He also consistently denied auditory hallucinations, and was consistently well groomed, with adequate hygiene. An August 2011 VA examination report reflects that the Veteran was clean and casually dressed with coherent speech, and cooperative attitude. His mood was anxious and affect was constricted; "dyskinetic" movements were observed. His attention was intact, but he was unable to do serial 7's or spell a word forward or backward. The Veteran was oriented to person and place but only partially oriented time. With regard to thought process, there was an overabundance of ideas and looseness of associations; he was preoccupied with one or two topics. Delusions, hallucinations, inappropriate behavior, obsessive/ritualistic behavior, panic attacks, and homicidal or suicidal thoughts were absent and his impulse control was good. The examiner noted that the Veteran was unable to perform daily living activities mainly due to physical and mental limitations. The examiner observed that the Veteran's remote memory was mildly impaired, his recent memory was severely impaired, and that the Veteran experienced recurrent and intrusive distressing recollections of events, had markedly diminished interest or participation in significant activities, had difficulty falling or staying asleep, had irritability, outbursts of anger, and had difficulty concentrating. The examiner diagnosed anxiety disorder and cognitive disorder and assigned a GAF score of 55, stating that the Veteran did not meet the stressor criterion of PTSD. However, the examiner also opined that his cognitive limitations overshadowed any other neuropsychiatric condition the Veteran might have been exhibiting. The examiner observed that the Veteran's mood instability limited his capacity to interact effectively on a sustained basis with others and that social functioning in work situations involving interactions with the public, responding appropriately to persons in authority, or cooperative behaviors involving coworkers was limited. Additionally, cognitive limitations interfered with the Veteran's ability to sustain focused concentration sufficiently long to permit the timely and appropriate completion of tasks, as well as adaptive activities such as paying bills and maintaining a residence. A June 2013 VA treatment record indicates that the Veteran was admitted to a VA facility after he verbalized suicidal thoughts to his family members, specifically by jumping from a cliff in his car; it is noted that his granddaughter found him driving around looking for a lake. The Veteran reported having an argument with his wife because she left him alone at the house, and it separately noted that the Veteran's wife had dementia and that this was very stressful for him. He reported an increase in depressive symptoms such as crying spells, and feelings of worthlessness and hopelessness. The Veteran's current diagnoses of major depressive disorder, dementia, and PTSD were reviewed. The Veteran was previously admitted in December 2012 and was noted to be high risk for suicide, and was monitored on an outpatient basis following this admission; however he consistently denied suicidal and homicidal ideation several times in the following months. The Veteran's thought process continued to be coherent, relevant, and logical, his communication and language skills remained intact, and treatment records note that the Veteran continued to live with his wife of 60 years, and that he remained in contact with his living adult children (one son had previously died of cancer), and that his son lived closed by and constantly checked in on the Veteran and his wife. The Veteran's daughter was also involved in assisting them, but less so than his son, because she lived further away, and that his granddaughter was also involved caring and checking up on him. The Veteran continued to consistently deny delusions, and auditory and visual hallucinations. An August 2013 evaluation submitted by a private psychologist concluded that the Veteran's PTSD warranted a disability greater than 50 percent and that his PTSD rendered him unemployable. Moreover, after reviewing current medical literature, this private psychologist concluded that given the "presumable relationship between PTSD and cognitive impairment" it was "more likely than not [that the Veteran's symptoms of cognitive impairment] are attributable to his PTSD." The private psychologist also concluded that when taking the Veteran's cognitive impairment into account, his disability clearly rendered him unemployable. This psychologist's evaluation was based upon a review of the Veteran's VA claims file, and discussed the Veteran's Parkinson's disease, cognitive memory disorder, and suspected dementia or Alzheimer's disease. This examiner extensively discussed the Veteran's memory impairment and the effect of that impairment in the Veteran's "capacity to utilized his ideational and thinking resources to analyze situations of his environment and to initiate adaptive problem solving processes" as documented in the December 2003 psychological assessment, and also noted the June 2004 psychiatric assessment attributing the Veteran's cognitive impairment to his anxiety. A September 2013 VA examination opinion provided in a response to a request to distinguish between symptoms associated with nonservice-connected disorders including major depressive disorder, Parkinson's disease, cognitive memory disorder, and dementia from his PTSD stated only that "regarding [the] etiology of the Veteran's cognitive limitations [they] can be [due] to multiple etiologies as previously documented." The Board finds, that based on the foregoing, the relevant medical evidence is at least in equipoise as to whether the Veteran's cognitive limitations were due to his PTSD (which is an anxiety disorder), or nonservice-connected conditions to include a major depressive disorder, dementia, and other cognitive disorders as discussed above. As such, the Board will attribute the Veteran's occupational impairment related to cognitive impairment and his memory issues to his service-connected PTSD condition consistent with Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), as it is not possible to distinguish between the cognitive impairment caused by his PTSD and non-PTSD conditions. In so finding, the Board observes that while, as stated in previous Board decisions, no VA examiner has attributed the Veteran's cognitive limitations to his PTSD, no VA examiner has clearly distinguished the Veteran's cognitive impairment due to nonservice-connected conditions from his PTSD, and there are numerous private examiner opinions that have attributed his cognitive impairment to his PTSD. Thus, while it may be the case that the Veteran's cognitive impairment stems from multiple etiologies as explained by the September 2013 supplemental opinion, without medical evidence that clearly distinguishes the Veteran's nonservice-connected cognitive impairment from his service-connected PTSD cognitive impairment, VA must attribute the nonservice-connected cognitive impairment to the Veteran's service-connected PTSD. Accordingly, the Board finds that the Veteran's PTSD meets the criteria for the next highest rating of 70 percent. In so finding, the Board notes that as documented by the record, the Veteran's PTSD symptoms fluctuated at various times over the course of the appeal period, and that while serious symptoms such as suicidal ideation were not constant, they did result in multiple suicide attempts over the course of the appeal period, and the Veteran had also intermittently exhibited suicidal ideation without intent or plan. Additionally, there is also significant evidence that the Veteran's depression was near continuous and affected his ability to function appropriately, independently, and effectively, and his ability to adapt to stressful circumstances, as demonstrated by significant increases in symptoms during periods of conflict with his wife and other family members, leading to suicidal ideation. Additionally, the Veteran's cognitive impairment, in particular severe memory impairment also manifested as occupational impairment resulting in the difficulty to adapt to stressful circumstances and function appropriately and effectively, causing deficiencies in mood and work. As for social impairment, although the Veteran appeared to have had a supportive relationship with his son, daughter and granddaughter, and a long marital history with his wife despite her own health issues with dementia towards the end of their marriage, there is evidence of conflicts, impaired impulse control and periods of irritability and verbal aggression that caused deficiencies in the area of family relations. As such, an award of entitlement to a 70 percent rating for service-connected PTSD is appropriate here. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.125, 4.130 Diagnostic Code 9411 (2017). In so finding, the Board has considered the next highest rating of 100 percent. However, the Board finds that criteria for total occupational and social impairment are not met. The Board finds that this is so because the Veteran had a long marital history and ultimately supportive relationships with multiple family members including his children, and he had also repeatedly demonstrated appropriate interpersonal behavior and cooperation at multiple mental status examinations, both VA and private. Additionally, there was no evidence of grossly inappropriate behavior, gross impairment in communication, persistent danger of hurting others, or that his memory loss was so severe as to cause him to forget his own name, occupation, or those of close relatives. Moreover, the Veteran consistently denied persistent delusions and auditory hallucinations, and had for the most part consistently denied visual hallucinations over the course of the appeal period (which is not consistent with persistent hallucinations). As such, because the Veteran's social impairment, while severe, was less than total, the 70 percent rating criteria more closely approximates his PTSD symptoms than the 100 percent rating criteria. III. Entitlement to a TDIU Total disability ratings for compensation may be assigned if the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16 (a) (2017). Such a rating is referred to as a TDIU. To be considered for assignment of a schedular TDIU the Veteran's service-connected disabilities must meet the following criteria: (1) if there is only one such disability, this disability shall be ratable at 60 percent or more; or (2) if there are two or more such 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. Id. However, to calculate whether the Veteran has a 60 percent rating or 40 percent rating for at least one disability, the following types of disabilities may be combined: (1) disabilities of one or both upper extremities, or of one or both lower extremities; (2) disabilities resulting from a common etiology or a single accident; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. Id. Such disabilities may be combined in accordance with 38 C.F.R. § 4.25, Table I (2017). Here, the Veteran has established service connection for PTSD, which by virtue of this decision has been assigned a 70 percent rating. This rating therefore, meets the minimum schedular eligibility requirements for TDIU entitlement. The remaining question is whether his service-connected disabilities precluded him from engaging in substantially gainful employment. See Moore v. Derwinski, 1 Vet. App. 356 (1991). Substantially gainful employment is work that is more than marginal, which permits the individual to earn a "living wage." Id. Notably, this inquiry must focus on whether, in light of his service-connected disorders, the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). Consideration may not be given to the veteran's age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). Factors to be considered in determining whether unemployability exists are the veteran's education and employment history, and loss of work-related functions due to pain. Ferraro v. Derwinski, 1 Vet. App. 326, 330, 332 (1991). There is significant lay and medical evidence as summarized above that the Veteran's PTSD to include cognitive impairment caused him to be unemployable and that his long-standing employment as a traveling salesman was ended largely due to his cognitive impairment to include memory issues that affected his job performance, including math errors, getting lost while driving, and losing track of merchandise, reduced reliability and productivity, the ability to interact effectively with others, and reliably appear for work. Additionally, a vocational assessment submitted in April 2017 who reviewed the Veteran's claims file, also concluded that the Veteran was precluded from securing and following substantially gainful occupation, when considering the Veteran's education, work history, and the limitations of service-connected PTSD. With regard to the Veteran's education history, the Board notes that a review of the Veteran's VA treatment records reveals that the Veteran did not finish high school and only completed formal education up through the eighth grade, and that prior to becoming a traveling vegetable salesman and active duty service, the Veteran worked as a migrant worker picking tomatoes. The April 2017 vocational assessment was largely predicated on extensive review of the May 1990, December 2003, 2004, 2011, and 2013 psychological and psychiatric assessments as summarized above. Based on the foregoing, the Board finds that there is sufficient positive evidence that the Veteran's service-connected PTSD rendered him unemployable, when considering the severity of the Veteran's PTSD to include cognitive impairment and his educational and work history. Accordingly, an award of entitlement to a TDIU due to service-connected PTSD is warranted here. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. § 3.102, 3.159, 3.340, 3.341, 4.16 (2017). ORDER Entitlement to a rating of 70 percent for service-connected PTSD is granted for accrued benefits or substitution purposes, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a TDIU is granted for accrued benefits or substitution purposes, subject to the law and regulations governing the payment of monetary benefits . S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs