Citation Nr: 1754765 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 13-24 554 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a low back disability. 4. Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) and major depression with alcohol and marijuana dependence. 5. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Christopher Loiacono, Agent WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from February 1969 to February 1971, including service in the Republic of Vietnam. The Veteran's decorations include the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In April 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. The issue of entitlement to service connection for a low back disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does not have a hearing loss disability for VA compensation purposes. 2. Affording the Veteran the benefit of the doubt, tinnitus was incurred in service. 3. During the period on appeal the Veteran's PTSD manifested symptoms resulting in impairment in daily life, cognitive abilities, mood and self-control. 4. At no time during the period on appeal did the Veteran's PTSD symptoms manifest complete social and occupational impairment 5. The Veteran's service-connected disability precludes substantially gainful employment. 6. Effective March 21, 2017, separate from his TDIU, the Veteran has additional service-connected disabilities independently ratable at 60 percent or more disabling. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.385 (2017). 2. Tinnitus was incurred in active service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for a rating of 70 percent disabling, and no higher, for posttraumatic stress disorder and major depression with alcohol and marijuana dependence, are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9411, 9434 (2017). 4. The criteria for an award of TDIU have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2017). 5. Effective March 21, 2017, separate from his TDIU, the Veteran has additional service-connected disabilities independently ratable at 60 percent or more disabling. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The Veteran claims entitlement to service connection for bilateral hearing loss and tinnitus. Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). For VA compensation and pension purposes, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran had normal hearing on examination at separation from service, but he marked "yes" to having hearing loss on his Report of Medical History at separation from service. The Veteran was afforded a VA examination in March 2013. On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 20 20 25 LEFT 20 15 15 20 25 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 98 in the left ear. The Veteran reported his ears buzz all the time, which has been happening for "years." The examiner reported that the Veteran was exposed to hazardous noise levels while in service but provided an opinion that based on electronic hearing testing conducted at enlistment and at discharge and the Veterans current audiological assessment it was the examiner's opinion that the Veterans hearing loss and reported tinnitus were less likely as not caused by or a result of noise exposure while in service. At the hearing before the undersigned the Veteran reported that he did not have any problem with his hearing before service and that he believed that his hearing loss occurred during service. He stated that big artillery guns would go off at night and he would sleep around them. He reported noise exposure while in the infantry. He stated that he never got treatment for his hearing loss. He hears the buzz and then he could hear his heart beat in his ears. He did not notice the buzz in his ears until shortly after service. The buzz has continued to the present. The Board finds that entitlement to service connection for bilateral hearing loss is not warranted. Based upon the examination results in March 2013, the Veteran does not have a bilateral hearing loss disability for VA purposes. 38 C.F.R. § 3.385. Absent competent evidence of the existence of a disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Therefore, entitlement to service connection for bilateral hearing loss is denied. The Board finds that entitlement to service connection for tinnitus is warranted. The March 2013 VA examination included a negative nexus opinion, essentially because there was no significant hearing threshold shift while in service. However, the Veteran testified that he first noticed his ears "buzzing" shortly after service. Affording the Veteran the benefit of the doubt, in consideration of the circumstances of his service and his exposure to loud noise in service and his competent and credible reports of buzzing in the ears since shortly after service to the present time, the Board finds that the Veteran's tinnitus was incurred in service. Charles v. Principi, 16 Vet. App 370 (2002). As such, entitlement to service connection for tinnitus is granted. II. Higher Evaluation Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran seeks an evaluation in excess of 50 percent PTSD and major depression with alcohol and marijuana dependence. The Veteran's disability is currently evaluated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9434-9411. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. 38 C.F.R. § 4.27. In this case, Diagnostic Code 9434 refers to major depression, while Diagnostic Code 9411 refers to PTSD. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. A rating of 70 percent is assignable 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 work like setting); inability to establish and maintain effective relationships. Id. A rating of 100 percent is assignable for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, consideration shall be given to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation will be based on all the evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of examination. It is the responsibility of the rating specialist to interpret reports of examinations in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (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. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (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 rating 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 Veteran was afforded a VA examination in October 2010. He reported lack of energy/fatigued, decreased attention/concentration, and disorientation. The Veteran had a severely restricted lifestyle, limited social support system except for family, isolation and withdrawal. He had reexperiencing with dreams/nightmares, intrusive thoughts, and flashbacks. He reported hallucinations. There was no inappropriate behavior, suicidal thoughts, or homicidal thoughts. The Veteran was able to maintain minimal personal hygiene and other basic activities of daily living. He was oriented to person, place, and time. He had near daily forgetfulness to a mild degree that caused decreased efficiency with employment and social functioning. He did not have any obsessive or ritualistic behavior that interfered with routine activities. The Veteran did not have any irrelevant, illogical or obscure speech patterns. The Veteran had panic attacks. He had daily anxiety that caused him to avoid crowds and people. He felt overwhelmed with tasks and worried quite a bit. He takes a break when he becomes angry or irritated. There was impaired impulse control. Sleep impairment was described as nightly and caused increased fatigue and decreased efficiency and stress tolerance. The Veteran was diagnosed with PTSD, major depression, recurrent and severe without psychotic features. The diagnoses could not be separated. A GAF of 52 was assigned. In an addendum dated in December 2010 the examiner restated the Veteran's symptoms. The examiner noted that the Veteran would have difficulty in a job that required his working and/or interacting with others on regular basis. However, jobs that allow him some degree of autonomy, the ability to work alone, and low stress would be more suitable for him. In a Social Security Administration (SSA) record it was noted that the Veteran had a consulting psychology report in February 2011. The Veteran was noted to get into arguments with co-workers. He was unable to concentrate and felt like he was not understanding what he was getting into with co-workers. He was constantly falling asleep due to the psychiatric medications the VA had prescribed for him. Mental status examination showed the Veteran to be casually dressed and hygiene was fair. He was alert and oriented. He was composed and appropriate for the situation he was slightly guarded. Affect was typically serious and appeared mood congruent. Mood was mostly depressed. He had hallucinations, which were noted to be more of illusions. There were no overt signs of anxiety or hypomania on examination. He reported nightmares. Social activities were limited. He used to have more friends but they didn't come around anymore. The Veteran was diagnosed with alcohol dependence, cannabis dependence, bipolar disorder NOS, specific phobia, and personality disorder. A GAF of 58 was assigned. Thought content was generally normal. There was no evidence of grossly disorganized behavior or marked confusion. Ability to communicate and level of conversation was fair. Word finding appeared normal without aphasia. Speech articulation was clear without dysarthria, dyspraxia or any other dysfluencies. Rate of speech was normal without slowing, speed, or pressure; production was below average. Ability to understand and comprehend simple language, in the form of simple verbal directions during the exam appeared fair. Ability to understand more complex diretions and language was below average to poor. Perceptual disturbances such as visual or auditory hallucinations were not clearly reported. Memory for past and recent life events and the presentation of personal history appeared fair. Judgment for confronting simple circumstances in daily life and understanding what was expected appeared below average. The ability to problem solve and consider alternatives was poor. Insight and ability to analyze or determine possible outcomes of events or behaviors appeared to be poor. Consequential thinking was below average to poor. Behavioral control was apparently poor around drinking and use of cannabis with his psychiatric medications. His ability to understand how his behavior affected others was below average. The Veteran's psychiatrist completed an impairment questionnaire in October 2011. The Veteran was diagnosed with PTSD, severe; THC dependence; and alcohol abuse. He was assigned a GAF score of 45. He had deficiencies in family relations, intermittent inability to perform activities of daily living, difficulty in adapting to stressful circumstances, intrusive recollections of a traumatic experience, persistent danger of hurting self or others, deficiencies in work or school, unprovoked hostility and irritability, inability to establish and maintain effective relationships, depression affecting the ability to function independently, appropriately, and effectively, neglect of appearance and hygiene, and suicidal ideation. The Veteran was moderately limited in his ability to sustain ordinary routine without supervision and maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness. He was markedly limited in his ability to remember locations and work-like procedures, maintain attention and concentration for extended periods, perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerance, work in coordination with or proximity to others without being distracted by them, complete a normal workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods, interact appropriately with the general public, accept instructions and respond appropriately to criticism from supervisors, ability to get along with co-workers or peers without distracting them or exhibiting behavioral extremes, respond appropriately to changes in the work setting, be aware of the normal hazards and take appropriate precautions, travel to unfamiliar places or use public transportation, and ability to set realistic goals or make plans independently. The provider stated that he felt that the Veteran was not capable of performing full time competitive work with his psychological symptoms and limitations. The earliest date of the symptoms and limitations was identified as 2007. The Veteran was markedly limited due to his PTSD chronic/severe. The Veteran was afforded a VA examination in March 2013. The Veteran reported having significant difficulty with his job including being stuporous or falling asleep due to medications that he was on at the time. He also reported having had significant problems with interpersonal conflicts including becoming irritable or angry with people who are normally very pleasant. He described having problems with comprehension such as not being able to understand procedures for reading barcodes or being in meetings and not understanding what people were talking about. He described having acute panic attacks when he would see rats in the warehouse in which he worked. When he would have panic attacks he would have to leave his work post and go outside and walk around the building for 15 or 20 minutes. He eventually decided that he could not safely do this job particularly as it required operating heavy equipment and he was also fearful of falling asleep driving to and from work. He reported chronic anxiety. He continued to have nightmares. He reported recurrent distressing recollections of service. He had panic attacks twice a week. He endorsed having visual imagery out of the corner of his eye of rats scurrying. He denied any auditory hallucinations. He was very isolative and generally avoided people and public places. He had very little interest in activities and reported feeling depressed much of the time. He also reported problems with concentration and memory. The Veteran's affect was quite restricted. Concentration, abstract reasoning and continuity of thought were adequate. Remote, recent and immediate memory appeared intact during the interview. He was assigned a GAF score of 51. There was reduced reliability and productivity due to PTSD and mental disorder signs and symptoms. This Veteran was able to maintain activities of daily living including personal hygiene. There was no inappropriate behavior. Thought processes and communication were not impaired. The Veteran's provider completed a psychiatric questionnaire in October 2013. The Veteran was diagnosed with PTSD, alcohol dependence, and marijuana dependence. The Veteran was assigned a GAF score of 40 with the lowest GAF over the prior year of 40 and the highest 60. The provider noted that the Veteran had memory loss for names of close relatives, own occupation, or own name, intermittent inability to perform activities of daily living, deficiencies in family relations, deficiencies in mood, persistent irrational fears, paranoid, difficulty in adapting to stressful circumstances, persistent delusions or hallucinations, intrusive recollections of a traumatic experience, persistent danger of hurting self or others, angry, disorientation to time or place, occasional unprovoked hostility and irritability, depression affecting the ability to function independently, appropriately, and effectively, deficiencies in judgment, neglect of personal appearance and hygiene, suicidal ideation, gross impairment in thought processes or communication, and inability to establish and maintain effective relationships. The Veteran was moderately limited in his ability to sustain ordinary routine without supervision, ability to accept instructions and respond appropriately to criticism from supervisors, and ability to travel to unfamiliar places or use public transportation. He was markedly limited in his ability to remember locations and work-like procedures, maintain attention and concentration for extended periods, perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerance, work in coordination with or proximity to others without being distracted by them, complete a normal workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods, interact appropriately with the general public, maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness, ability to get along with co-workers or peers without distracting them or exhibiting behavioral extremes, respond appropriately to changes in the work setting, be aware of the normal hazards and take appropriate precautions, and ability to set realistic goals or make plans independently. The provider stated that the Veteran was not able to perform gainful employment with the symptoms and limitations stemming from his psychological impairment. The impairment was noted to be from January 2011. In July 2013 the Veteran was noted to be suicidal and have a gun. The Veteran was afforded a VA examination in January 2017. The Veteran was diagnosed with PTSD, other specified depressive disorder, specific phobia, and alcohol use disorder. The Veteran described symptoms of depression, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Hygiene and grooming were good. His eye contact and his gross psychomotor skills were within normal limits. Speech was within normal limits in rate, volume, fluency and prosody. His mood was dysthymic and his affect was congruent, appropriate to content. He was alert and oriented to all spheres and his thought processes were linear, logical and goal directed. He was attentive and showed no significant signs of distractibility. He was appropriately interactive and exhibited normal comprehension and expression. He denied perceptual disturbances, and no disordered thought processes were observed; there was no obvious evidence of sensory impairment. The Veteran appeared to have intact judgment and impulse control. He had adequate insight. The Veteran denied current suicidal ideation or homicidal ideation, intent or plan. He was able to maintain activities of daily living including personal hygiene, self-care and household chores. There was no evidence of any recent inappropriate behavior. In July 2017 a private psychotherapist reported that the Veteran's PTSD was very severe. The provider noted that the Veteran experienced total occupational and social impairment due to his paranoia and inability to be around other people. He was unable to get along with other people, including most of his family members. The provider did not observe any impaired thought processes, although the Veteran did seem a bit confused. The Veteran demonstrated deficiencies in areas of work, social relationships and family relations. He suffered from anxiety attacks, suicidal ideation, and difficulty adapting to stressful work related situations. The provider rendered the opinion that the Veteran was not capable of working either full or part time due to his service-connected psychiatric impairment. A July 2017 psychiatric impairment questionnaire was associated with the claims file. The Veteran was diagnosed with severe PTSD and depression. He had a GAF score of 50 with the lowest of 48 over the prior year and 50 as the highest. The Veteran was noted to have intermittent inability to perform activities of daily living, deficiencies in family relations, deficiencies in mood, persistent irrational fears, difficulty in adapting to stressful circumstances, intrusive recollections of a traumatic experience, speech intermittently illogical, obscure, or irrelevant, deficiencies in work or school, unprovoked hostility and irritability, inability to establish and maintain effective relationships, depression affecting the ability to function independently, appropriately, and effectively, and suicidal ideation. He had little to no interaction with other people. The Veteran was mildly limited in the ability to remember locations and work-like procedures. The Veteran was moderately limited in his ability to perform activities within a schedule, maintain regular attendance and be punctual within customary tolerance, maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness, and ability to set realistic goals or make plans independently. He was markedly limited in his ability maintain attention and concentration for extended periods, sustain ordinary routine without supervision, work in coordination with or proximity to others without being distracted by them, complete a normal workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods, interact appropriately with the general public, accept instructions and respond appropriately to criticism from supervisors, get along with co-workers or peers without distracting them or exhibiting behavioral extremes, ability to get along with co-workers or peers without distracting them or exhibiting behavioral extremes, and respond appropriately to changes in the work setting. The Veteran was unable to adapt to stress in work situations and cannot get along with coworkers. During the period on appeal the Veteran's treatment records did not reveal impairment of grooming, hygiene, affect, cognition, or orientation. The Veteran's insight and judgment ranged from poor to fair. The Veteran was reported to indicate that he felt safe being isolated and not interacting with friends and that he did not have any family nearby. Treatments notes did not reveal any report of an inability to perform activities of daily living. Treatment notes reveal reports of visual hallucinations, fears, panic attacks, and difficulty with concentration, memory, and comprehension. GAF scores ranged from 45 to 65. At the hearing before the undersigned the Veteran reported that he did not have any friends. He did not deal with family too much and only talked to one of his sisters. The Board finds that during the entire period on appeal the Veteran's PTSD manifested symptoms more nearly approximating an evaluation of 70 percent disabling. During the period on appeal the Veteran's psychiatric disability manifested sleep problems, anxiety, intrusive memories and flashbacks, memory problems, decreased attention and concentration, panic attacks, isolation and withdrawal, nightmares, intermittent inability to perform activities of daily living, neglect of personal appearance and hygiene, suicidal ideation, impaired impulse control, and hallucinations. As such, the Veteran's psychiatric disability manifests deficiencies in most areas, including work, family relations, judgment, thinking, and mood due to symptoms including suicidal ideation, neglect of personal appearance, and inability to establish and maintain effective relationships. Therefore, an evaluation of 70 percent disabling is granted. However, review of the claims file does not reveal that the Veteran's psychiatric disability manifests total social and occupational impairment. Although a July 2017 provider indicated that the Veteran experienced total occupational and social impairment, other treatment records from July 2017 indicate that the Veteran was assigned a GAF score of 50, representing serious symptoms. In addition, the provider noted that the Veteran remained in contact with his cousin. Lastly, the preponderance of the evidence during the period on appeal reveals that the Veteran does not have grossly inappropriate behavior or an inability to perform activities of daily living. As such, the Board finds that the evidence is against a finding that the Veteran is totally socially and occupationally impaired and an evaluation in excess of 70 percent for PTSD is denied. III. TDIU The Veteran seeks entitlement to a TDIU. In order to establish entitlement to TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, 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). Consideration may be given to the Veteran's level of education, special training, and previous work experience when arriving at this conclusion, but factors such as age or impairment caused by non-service-connected disabilities are not to be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, 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). Above the Board grants entitlement to an evaluation of 70 percent disabling for PTSD for the entire period on appeal. As such, the Board finds that the Veteran meets the schedular criteria for award of at TDIU. 38 C.F.R. § 4.16(a). He is also service-connected for lymphoma, evaluated as 100 percent disabling from March 21, 2017. In October 2010 the Veteran was noted to have had near daily forgetfulness to a mild degree that caused decreased efficiency with employment. In a December 2010 application for TDIU the Veteran reported that he was unemployed due to his PTSD and that the last time he worked was in July 2010. He reported four years of college and a work history from 1977 to 2010 in "warehouse" work. In a March 2011 request for employment information, the Veteran was noted to have retired in July 2010. In a December 2010 VA examination addendum, the examiner noted that the Veteran would have difficulty in a job that requires his working and/or interacting with others on regular basis. On the other hand, jobs that allow him some degree of autonomy, the ability to work alone, and low stress would be more suitable for him. In October 2011 a provider stated that he felt that the Veteran was not at all capable of performing full time competitive work with his psychological symptoms and limitations. The earliest date of the symptoms and limitations was identified as 2007. The Veteran was markedly limited due to his PTSD chronic/severe. In April 2011 the Veteran reported that he did not let his employer know of his medication or therapy because he feared being fired or demoted. He stated that when he left the company he informed the president of what he had been going through over the years and that he could not take it anymore. Some of his co-workers that worked closely with him knew of his mental condition. Upon examination in March 2013 the Veteran reported that he was having problems with comprehension and could not safely do his job. The Veteran was having difficulty functioning at work and would have periods when he would leave his work duties due to panic attacks. He also reported complications from his psychiatric medications that were causing him to fall asleep and potentially be unsafe while driving a forklift truck. In October 2013 a provider reported that the Veteran was not able to perform gainful employment with the symptoms and limitations stemming from his psychological impairment. The impairment was noted to be from January 2011. A VA medical opinion was obtained in January 2017. The examiner noted that from a psychiatric perspective, the Veteran retained cognitive, emotional, and behavioral capacity to engage in at least simple tasks in a loosely supervised environment. His fluctuations in mood suggested that he would perform best in a position where there is low stress and flexibility, and no time pressure. His irritability and anger indicate that he would work best in an environment where he could perform tasks alone or with minimal intrusion from others; he may have difficulty managing differences of opinion or negative feedback. He may also have difficulty maintaining working relationships with colleagues and interact appropriately with the public. The Veteran's anhedonia and depressed mood would impact his ability to motivate himself to initiate and persist on tasks. The Veteran's intrusive memories, heightened anxiety, and hypervigilance would impair his ability to focus and persist on tasks. His insomnia results in fatigue during the day, which impacts his concentration, mental efficiency, and overall productivity. His concentration and memory inefficiencies impact his ability to understand, remember and execute complex instructions, learn efficiently, remember details, and to multi-task. He may have difficulty with executing good judgment and work-related decisions. He could function in a setting that does not require engagement with the public or customer interaction, and that limits external distractions. He could do something independently, or with minimal and loose supervision. At the April 2017 hearing, the Veteran said he had obtained a degree from a junior college, but had no other training. He said he last worked in 2010 and had problems with people, was drowsy because of medications related to PTSD and could not learn new technologies because PTSD caused problems concentrating. In July 2017 a provider reported that the Veteran became unable to work due to his service-connected psychiatric impairment in 2008. Considering the Veteran's work and education history, the reports of his providers as well as the deficiencies identified by the VA examiners, and affording the Veteran the benefit of the doubt, the Board finds that the Veteran's psychiatric disability renders him unemployable for the entire period on appeal. Thus, entitlement to a TDIU for the entire period on appeal is granted. IV. Special Monthly Compensation VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008). SMC is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). In this case, with consideration of the above, as of March 21, 2017, the Veteran is in receipt of an award of TDIU based solely on his psychiatric disability and in receipt of service connected benefits for marginal zone lymphoma, evaluated as 100 percent disabling. As such, the criteria for SMC at the housebound rate under 38 U.S.C. § 1114 (s) have been met, effective March 21, 2017. ORDER Service connection for bilateral hearing loss is denied. Service connection for tinnitus is granted. Entitlement to an evaluation of 70 percent, and no higher, for posttraumatic stress disorder and major depression with alcohol and marijuana dependence, is granted, subject to regulations governing payment of monetary awards. Total disability rating based upon individual unemployability is granted, subject to regulations governing payment of monetary awards. Special monthly compensation at the housebound rate is granted, effective March 21, 2017, subject to the regulations governing payment of monetary awards. REMAND Upon the Report of Medical History at separation from service the Veteran reported back trouble. Service treatment records reveal complaints of back pain in the lumbar area. See, e.g., July 1970. The Veteran was afforded a VA examination regarding the etiology of his back disability in March 2013. After examination the examiner rendered the opinion that the Veteran's back disability was less likely than not incurred in or caused by complaints of back pain during military service. The examiner stated that the Veteran suffered from muscle irritation during service and that his current condition was a new and separate condition, which was degenerative in nature. Although the examiner opined that the Veteran's current disability is not the same disability as the condition that the Veteran complained of in service, the examiner did not render an opinion regarding whether the Veteran's current disability was due to the Veterans active service. Therefore, as the opinion rendered is not adequate, the issue must remanded to obtain a new opinion. On remand, attempts must be made to obtain and associate with the claims file all VA treatment records regarding the Veteran dated since April 2017. See 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. Take all appropriate action to obtain and associate with the claims file all VA medical records regarding the Veteran dated since April 2017. Any additional pertinent records identified by the appellant during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the appellant, and associated with the claims file. 2. Thereafter, schedule the Veteran for an appropriate examination to determine the nature and likely etiology of any diagnosed low back disability. The claims file and copies of all pertinent records should be provided to the examiner for review. Based on the examination and review of the record, the examiner should address the following: (a) Identify all disabilities related to the back. (b) For any currently diagnosed back disability, is it at least as likely as not (50 % probability) that it is causally related to service? The examiner must comment on the Veteran's reported injuries in service. The examiner should provide an explanation for any opinion provided. 3. Thereafter, readjudicate the Veteran's claim. If the benefit sought on appeal is not granted, issue the Veteran and his representative a supplemental statement of the case and provide an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs