Citation Nr: 1718035 Decision Date: 05/24/17 Archive Date: 06/05/17 DOCKET NO. 15-09 615 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD M. Wulff, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1954 to March 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The Board notes that the issue on appeal was characterized by the RO as entitlement to service connection for PTSD. However, in light of the Veteran's assertions and the evidence of record, the Board has recharacterized the issue more broadly to include any acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). The Veteran testified at a hearing before the undersigned Veterans Law Judge in January 2017. A transcript of that proceeding is associated with the record. During the January 2017 hearing, the Veteran testified that he suffered from a bilateral hand disorder. The Board notes that the Veteran is currently service-connected for residuals of a left index finger fracture (claimed as a left hand disorder). However, service connection has not been established for a right hand disorder. If he would like to seek service connection for such a condition, the Veteran and his representative should submit a claim to the RO. 38 C.F.R. §§ 3.155, 3.157. This appeal was processed using the Virtual VA and the Veterans Benefits Management System (VBMS) electronic claims processing systems. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic records. The Board notes that additional VA medical records and VA vocational rehabilitation records have been associated with the VBMS file since the most recent statement of the case. However, as the Board is granting the benefits sought on appeal in full, there is no prejudice to the Veteran in proceeding with adjudication of the claims at this time. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2015). FINDINGS OF FACT 1. The Veteran has a current acquired psychiatric disorder, variously diagnosed as PTSD, other specified trauma and stress-related disorder, and depression, that is related to his military service. 2. The Veteran has met the schedular requirement for TDIU, and his service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, an acquired psychiatric disorder, variously diagnosed as PTSD, other specified trauma and stress-related disorder, and depression, was incurred in active service. 38 U.S.C.A. § 1110 (West 2015); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2016). 2. Resolving all reasonable doubt in favor of the Veteran, the criteria for entitlement to TDIU have been met. 38 U.S.C.A. § 1155 (West 2015); 38 C.F.R. § 3.50, 3.102, 3.340, 3.341, 3.1000, 4.16 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Acquired Psychiatric Disorder Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). A mental disorder diagnosis must conform to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), or, for claims received by or pending before the AOJ on or after August 4, 2014, the DSM-5 (Fifth Edition). See 38 C.F.R. §§ 4.125, 4.130; 79 Fed. Reg. 45093 (Aug. 4, 2014). In this case, the Veteran's claim was certified to the Board on March 27, 2015; therefore, the regulations pertaining to the DSM-V are for application. If the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of that veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(2). Effective July 13, 2010, if a stressor claimed by a veteran is related to that veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that a veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of that veteran's service, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). "[F]ear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See id. If a claimed stressor is not related to combat or fear of hostile or military activity, then a veteran's lay statements, alone, would not be sufficient to establish the occurrence of the alleged stressor; rather, corroborating evidence would be needed to support the claim for service connection. See Cohen v. Brown, 10 Vet. App. 128, 147 (1997); Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). See also Zarycki v. Brown, 6 Vet. App. 91, 98 (1993); Doran v. Brown, 6 Vet. App. 283, 289-290 (1994). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran has contended that he developed a psychiatric disorder as a result of exposure to hostile military activity during his service in the Republic of Vietnam. See, e.g., January 2017 Board hearing transcript, at 5. Specifically, the Veteran has reported that he was exposed to rocket and mortar attacks while stationed on the flight line at Bien Hoa Air Force Base. See, e.g., December 2014 statement in support of claim. He also described witnessing the aftermath of a rocket attack on his unit's barracks. In addition, the Veteran reported that he was present during a rocket attack on an NCO Club in approximately 1968 that resulted in the death of a club manager. The Veteran's service personnel records show that he was awarded the Air Force Commendation Medal for meritorious service while he was stationed at the Bien Hoa Air Force Base in the Republic of Vietnam from May 1969 to October 1969. The award citation further noted that the Veteran's efforts significantly contributed to the combat mission, despite adverse weather conditions, long and arduous working hours, and the hazards of the combat environment. The Veteran's service treatment records show that he had a normal psychiatric evaluation at the time of his May 1954 enlistment examination. Additionally, in an associated report of medical history, the Veteran denied having a medical history of depression or excessive worry. Notably, however, the Veteran reported having depression or excessive worry in a subsequent August 1958 report of medical history. The post-service VA medical records also document numerous diagnoses of chronic PTSD and major depression. See, e.g., November 2012 and October 2013 VA mental health records. During a June 2011 VA examination, the Veteran reported that he was exposed to rocket fire while stationed on a flight line in Vietnam. He also described seeing the remains of soldiers who were killed during an attack on his unit's barracks. The examiner diagnosed the Veteran with anxiety disorder, not otherwise specified (NOS), and indicated that his depression was in remission. She explained that the Veteran's symptoms were subclinical and subdiagnostic for PTSD. Specifically, his symptoms of hypervigilance and avoidance were not sufficient in frequency, intensity, or duration to support a diagnosis of PTSD. The examiner did note that the Veteran's stressors satisfied the criterion for a diagnosis of PTSD and were related to his fear of hostile military or terrorist activity. She opined that the Veteran's depression was most likely related to his cancer and that his current occasional mood disturbances were related to chronic pain and discomfort. In December 2011, Dr. R.K. (initials used to protect privacy), a VA psychiatrist, opined that the Veteran's symptoms of PTSD were much more likely than not caused by traumatic experiences during his four years and three months of service in Vietnam. In so finding, Dr. R.K. considered the Veteran's reported in-service stressors. In particular, the Veteran reported that he was exposed to rocket fire and that he saw the remains of soldiers that were killed and injured during an attack on his barracks at the Bien Hoa Air Force Base. He also stated that he was in an NCO Club when it was hit by rocket fire. Dr. R.K. noted that the Veteran feared he was going to die and that he made himself feel numb and invincible to cope with the stress. During a March 2014 VA examination, the Veteran reported that he was subjected to numerous rocket attacks while serving in Vietnam. He also reported that he witnessed the aftermath of an attack on his unit's barracks. The examiner indicated that the Veteran's stressors were adequate to support a diagnosis of PTSD and were related the Veteran's fear of hostile military or terrorist activity. However, the examiner determined that the Veteran did not satisfy the criteria for a diagnosis of PTSD. Rather, she diagnosed the Veteran with other specified trauma and stress-related disorder and noted that he had mild subclinical depression. The examiner opined that the Veteran's other specified trauma and stress-related disorder was more likely than not due to exposure to combat while serving in Vietnam. She further opined that the Veteran's mild subclinical depression was likely due to psychosocial stressors. The Board notes that the June 2011 and March 2014 VA examiners determined that the Veteran's stressors were adequate to support a diagnosis of PTSD and were related to his fear of hostile military or terrorist activity. In so doing, the examiners specifically considered the Veteran's stressors relating to his exposure to rocket fire and the aftermath of the attack on his unit's barracks. The Veteran's service personnel records also note that he served in an area with combat hazards. As such, his stressors are consistent with the places, types, and circumstances of his service. Therefore, an in-service stressor is established. The Board acknowledges that the June 2011 and March 2015 VA examiners determined that the Veteran did not satisfy the criteria for a diagnosis of PTSD. However, the VA examiners did not address the numerous VA medical records showing diagnoses of PTSD. Moreover, Dr. R.K., a VA psychiatrist, diagnosed the Veteran with PTSD on numerous occasions and related the disorder to his experiences in Vietnam. Cohen v. Brown, 10 Vet. App. 128, 139, 140 (1997) (mental health professionals are presumed to know the requirements applicable to their practice and to have taken them into account when diagnosing PTSD). Significantly, there are no contrary medical nexus opinions of record. In this regard, although the March 2014 VA examiner diagnosed the Veteran with other specified trauma and stress-related disorder, he nevertheless provided a positive nexus opinion. Moreover, the June 2011 VA examiner opined that the Veteran's depression was most likely related to his cancer and that his current occasional mood disturbances were related to chronic pain and discomfort. However, she did not otherwise address whether the Veteran's psychiatric disorder was related to his military service. With regard to the Veteran's diagnosis of depression, the March 2014 examiner opined that the Veteran's mild subclinical depression was likely due to psychosocial stressors, to include his chronic illnesses. The Board notes that the March 2014 examiner did not identify the specific chronic illnesses. However, the opinion is consistent with the June 2011 VA examiner's opinion that the Veteran's depression, in remission, was most likely due to his cancer. To the extent that the VA opinions of record attributed depression to cancer, the Board notes that the Veteran is currently service-connected for prostate cancer. 38 C.F.R. § 3.310. Based on the foregoing, and resolving reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted for an acquired psychiatric disorder, variously diagnosed as PTSD, other specified stress disorder, and depression. II. TDIU VA disability ratings are based, as far as practicable, on the average impairment of earning capacity attributable to disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Id. Where the schedular rating is less than total, a total disability rating may nonetheless be assigned 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 disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. See 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). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. §§ 3.341(a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or maintain employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to TDIU. The Veteran is currently service-connected for the following disabilities: degenerative disc disease and arthritis of the lumbar spine, assigned a 20 percent evaluation; prostate cancer, status post external beam radiation with proctitis and urinary incontinence, assigned a 20 percent evaluation; right lower extremity radiculopathy, assigned a 20 percent evaluation; left lower extremity radiculopathy, assigned a 10 percent evaluation; right Achilles tendon rupture, status post repair, assigned a 10 percent evaluation; right eye residuals of glaucoma status post iridectomy, assigned a 10 percent evaluation; right knee degenerative arthritis with asymptomatic scar, assigned a 10 percent evaluation; fecal incontinence, assigned a 10 percent evaluation; hemorrhoids, assigned a noncompensable evaluation; left knee degenerative arthritis, assigned a noncompensable evaluation; residuals of a left index finger fracture (also claimed as left hand condition), assigned a noncompensable evaluation; and erectile dysfunction, assigned a noncompensable evaluation. The Veteran's combined rating is 70 percent, with one 40 percent disability based on the lumbar spine disability and bilateral radiculopathy resulting from a common etiology. 38 C.F.R. § 4.16 (a). Thus, the Veteran has met the schedular criteria for TDIU. Accordingly, the remaining question is whether he is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. A review of the evidence of record reflects that the Veteran was a self-employed upholsterer following his separation from service from approximately 1979 to 1994. See, e.g., November 2007 VA vocational evaluation. He worked as a custodian from approximately 1996 to 1998 and thereafter worked part-time until approximately 2004. See, e.g., November 2007 VA vocational evaluation and January 2017 Board hearing transcript, 25. A November 2004 VA examination noted that the Veteran had a slight functional impairment due to mild degenerative joint disease of the left index finger. The record also contains a November 2007 VA vocational assessment. The vocational evaluator noted that the Veteran had a high school degree and three years of college experience. He had also received a certificate in water and sewage treatment. The vocational evaluator concluded that the Veteran's leg, back, knee, and sciatic nerve disabilities precluded skilled labor. She further indicated that his finger and hand conditions prevented him from working in manually-driven careers. The Board acknowledges that the vocational rehabilitation evaluation also discussed the impact of nonservice-connected conditions, to include a right hand disorder. Nevertheless, the Board still finds the assessment probative, as the evaluator provided a detailed description of functional impairments due to the Veteran's service-connected disabilities. In a December 2007 independent living assessment, the evaluator noted that the Veteran had mobility and exertional limitations. He was able to walk and stand for short periods with support, but needed to alternate between sitting and standing. He had difficulty bending at the waist, and at times, he could not stoop, crouch, or kneel. His physical conditions also limited him from carrying, lifting, pushing, or pulling. Additionally, he had limited hand/finger use and grip strength. The evaluator noted that the Veteran had limited exposure to computer operation and the internet. He concluded that an ergonomic chair with a high back and lumbar support would enable the Veteran to sit at a computer for more than a short time. In a February 2008 statement, the Veteran's spouse reported that his hands and legs prevented him from doing physical work. She also stated that the Veteran needed to wear pads and have immediate access to a bathroom because of his urinary and fecal incontinence. In a February 2008 statement, a VA vocational rehabilitation counselor indicated that the Veteran was unemployable due to the severity of his service-connected disabilities. In so finding, the evaluator stated that the Veteran's genitourinary issues caused frequent urinary issues and incontinency. She noted that the Veteran required the use of pads for his urinary incontinency and needed to be in close proximity to a bathroom at all times. The evaluator indicated that the frequency of his use of the bathroom would significantly impact his ability to work. The evaluator further noted that the Veteran's back disorder with radiculopathy impacted his ability to walk, stand, bend, stoop, lift, and carry. She concluded that the Veteran was unemployable and indicated that there was no reason to believe that he could ever return to substantial competitive employment. In a June 2008 private medical statement, Dr. M.D.B.A. (initials used to protect privacy) stated that the Veteran was permanently disabled because of progressive and severe back problems. In August 2009, the Veteran reported that he was unable to work in his field of professional training due to his back problems. He indicated that he used a large quantity of diapers to compensate for his urinary incontinency. He further reported that he was unable to stand for prolonged periods due to increased numbness in his right leg and that he was unable to perform any type of manual dexterity due to his hands. In a November 2009 VA examination, the examiner noted that the Veteran used incontinence appliances one to two times per day. If the Veteran left his house or walked extensively, he always had fecal incontinence. The examiner indicated that the Veteran's urinary incontinence would not have any effect on his usual occupation, but would require immediate bathroom access due to his fecal incontinency. The examiner further stated that the Veteran's spine disorder would limit lifting, carrying, ambulating, climbing, pushing, and all lower body impacting activities. On his May 2010 application for TDIU, the Veteran reported that his back disability affected his full-time employment in August 1994 and that he became too disabled to work in April 2005. He stated that he attempted to work part-time, but stopped because of his back pain. He also reported that he had two years of college experience. In September 2010, the Veteran reported that he worked as an upholsterer after his separation from service, but was unable to continue working full-time because of his back, shoulder, and finger pain. He also worked as a custodian, but the position required movement and bending. In a May 2011 VA general examination, the examiner stated that the Veteran needed to be near a bathroom at all times and required frequent breaks due to urinary and fecal leakage. With regard to the Veteran's back disability, the examiner stated that the condition would not prevent sedentary employment provided that he was permitted to take frequent breaks and used a cane for ambulation. With regard to the Veteran's left finger disability, the examiner stated that the condition did not cause any employment restrictions. In so finding, he noted that the Veteran's dexterity for twisting, probing, writing, touching, and expression was normal. With regard to the Veteran's bilateral knee disabilities, the examiner stated that the Veteran's ability to perform employment tasks that required climbing and running would be limited and that he would require the use of a cane for prolonged walking or standing. However, the examiner indicated that sedentary employment would be feasible. In December 2011, Dr. D.K., a VA psychiatrist, opined that the Veteran was unemployable and permanently and totally disabled. He indicated that the Veteran's PTSD symptoms were not likely to improve during the remainder of his life. The Veteran's VA medical records show that Dr. D.K. reiterated his opinion on numerous occasions. See, e.g., February 2012, October 2013, and January 2014 VA medical records. During a March 2014 VA psychiatric examination, the Veteran reported that he was last employed as a janitor in 2005. He also reported that he worked as a self-employed auto upholsterer for 11 years. The examiner indicated that the Veteran's other specified trauma and stress-related disorder resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or, symptoms controlled by medication. During a June 2015 VA spine examination, the Veteran reported that he had numbness in his legs with prolonged standing, and difficulty lifting or bending. The examiner stated that the Veteran's spine condition would cause difficulty performing tasks that required bending, lifting, prolonged standing, and walking, but would not impair his ability to complete sedentary tasks. During the January 2017 hearing, the Veteran testified that he is unable to work due to his physical disabilities, including his back and hand disorders. He reported that he was self-employed as an upholsterer until approximately 1996 and that he stopped working due to a disagreement with his co-workers. Thereafter, he worked as a custodian until approximately April 2005. He further testified that he completed two years of college. In this case, the evidence clearly indicates that the Veteran is limited in his ability to perform physical activity due to his service-connected degenerative disc disease and arthritis of the lumbar spine, bilateral knee degenerative arthritis, and bilateral radiculopathy. The evidence as to whether his service-connected disabilities render him unable to follow or maintain sedentary work is less clear. In this regard, the May 2011 and June 2015 VA examiners indicated that the Veteran's lumbar spine, bilateral knee degenerative arthritis, and bilateral radiculopathy would not prevent sedentary employment. In addition, the November 2009 and May 2011 VA examiners did not find that the Veteran's urinary and fecal incontinence prevented employment. However, the VA examiners did not consider the combined impact of the Veteran's service-connected disabilities. Moreover, although medical examiners are responsible for providing a full description of the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet.App. 376, 381 (2013), the ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator, Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Here, the medical and lay evidence of record clearly shows that the Veteran requires immediate access to a bathroom and frequent breaks due to his urinary and fecal incontinency. See, e.g., August 2009 statement in support of claim; February 2008 statement; May 2011 VA examination. The Veteran's past work experience consisted mainly of upholstery work and physical labor. Moreover, although the Veteran completed two years of college, he has limited experience with computers and sedentary employment. The Board acknowledges that the Veteran has reported physical limitations due to a bilateral hand disorder. However, service connection is not in effect for a right hand disorder, and the Board may not consider the effects of nonservice-connected disabilities on his ability to function. With regard to the Veteran's service-connected left finger disability, the May 2011 VA examiner stated that the Veteran had no employment restrictions due to the disability. However, the examiner's opinion does not appear to have considered all relevant evidence. In this regard, the Board notes that a November 2004 VA examiner stated that the Veteran had slight impairment due to his mild degenerative joint disease of the left index finger. Moreover, the Veteran has reported ongoing pain and limitations since that time. In particular, a March 2013 VA medical record noted that the Veteran reported that he could not use his fingers to take his wallet out of his pockets. As such, there is evidence that the Veteran's service-connected left finger may cause some occupational impairment. The Veteran's VA medical records also suggest that the Veteran has some occupational impairment due to the acquired psychiatric disorder granted herein. Further medical inquiry could be undertaken with a view towards development of the claim. Specifically, the Board could seek a more definitive medical examination to address the combined effects of the Veteran's service-connected disabilities and the degree of impairment caused by his left finger disability. However, under the law, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). Based on all evidence of record and resolving all reasonable doubt in favor of the Veteran, the Board finds that the combined effects of the Veteran's service-connected disabilities, to include degenerative disc disease and arthritis of the lumbar spine, bilateral radiculopathy, bilateral knee degenerative arthritis, residuals of a left index finger fracture, urinary incontinence, and fecal incontinence, preclude substantially gainful employment. ORDER Service connection for an acquired psychiatric disorder, variously diagnosed as PTSD, other specified trauma and stress-related disorder, and depression, is granted. Entitlement to TDIU is granted, subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs