Citation Nr: 1801591 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 14-10 585 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an increased evaluation in excess of 50 percent disabling for post-traumatic stress disorder (PTSD) with bipolar disorder. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Jeffrey Bunten, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Coogan, Associate Counsel INTRODUCTION The Veteran had active service in the U.S. Army from February 1979 to February 1982 and from March 1983 to March 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ) in August 2017. A transcript of the hearing is of record. During the course of this appeal, specifically, during the August 2017 video conference hearing, the issue of entitlement to a total disability rating based on individual unemployability (TDIU) was raised by the Veteran, and is therefore within the jurisdiction of the Board. Rice v. Shinseki, 22 Vet. App. 447 (2009). FINDINGS OF FACT 1. The Veteran's PTSD with bipolar disorder more nearly approximates occupational and social impairment with deficiencies in most areas. Total occupational and social impairment is not demonstrated. 2. The medical and other evidence of record reasonably demonstrates that the Veteran's service-connected PTSD with bipolar disorder has made him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating, but not higher, for PTSD with bipolar disorder, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9432 (2017). 2. Resolving all reasonable doubt in favor of the Veteran, the criteria for entitlement to a TDIU, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. 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 to duty to assist argument). Increased Ratings The Veteran is seeking a rating higher than 50 percent for his post-traumatic stress disorder (PTSD) with bipolar disorder, asserting that his disability is more severe than reflected in the assigned 50 percent rating. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. See 38 U.S.C. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such diseases or injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7 (2017). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran's service-connected PTSD with bipolar disorder is currently rated at 50 percent, under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9432 (Bipolar disorder). A General Rating formula for evaluating all psychiatric impairment other than eating disorders contains the actual rating criteria for evaluating the Veteran's disability. Pursuant to this General Rating formula, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately, and effectively; impaired impulse control (e.g., unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (e.g., work or work like setting); inability to establish/maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9432, General Rating Formula for Mental Disorders. VA treatment records from late 2013 and early 2014 noted that the Veteran reported having auditory hallucinations, often with voices calling him by name and telling him to come with them. See, e.g., September 2013 VA treatment record (not hearing voices this last week and hasn't had any suicidal thoughts); October 2013 VA treatment record (started hearing voices about 6-7 months ago, frequency has increased over last 2-3 months; they call him by name and want him to leave his body, but no suicidal ideation at this time); November 2013 VA treatment record (auditory hallucinations about 2-3 times weekly, saying come with me; also experiencing depression); December 4, 2013 VA treatment record (reports intermittent voices); January 14, 2014 VA treatment record ("unremitting auditory hallucinations"); January 21, 2014 VA treatment record (patient reported hallucinations in early December, but did not report them today). An August 2011 VA treatment record reported that the Veteran lived alone, complained of feeling anxious, did not feel like being around people, and stayed home most of the time. A November 2011 Telephone Encounter Note said that the Veteran reported he was having panic/anxiety attacks because he didn't understand the information being taught in the classes he was taking. A few VA treatment records document that the Veteran had suicidal thoughts during the appellate period. For example, a May 2013 VA Mental Health Note stated the Veteran reported some suicidal ideation over the last few weeks as his stress level had increased, but with no specific plan or intent. An August 2013 VA treatment record said the Veteran reported feeling better today, but reported three weeks ago he was feeling depressed and staying in bed most of the time, and thought of hurting himself once, although he was not currently having suicidal or homicidal ideations. This record also noted the Veteran lived alone and did not socialize. It noted the Veteran had moderate tremors in both hands, and his license to drive had been suspended due to a seizure disorder. The Veteran has had two VA examinations for his psychiatric condition during the appellate period at issue, in October 2011 and January 2014. In the October 2011 PTSD VA examination, the Veteran was upset at the beginning of the session, voicing frustration that he was unable to get help through the VA for his mental health concerns, and that the examiner did not want to help him. The VA examiner was able to address the Veteran's initial concerns and the examination began. Later in the examination, however, the Veteran became so angry and frustrated that he abruptly left, and the examination could not be completed. The October 2011 VA examiner noted that he could not form complete opinions or give a complete report because the Veteran had broken off the examination, but the VA examiner was able to provide some information, based on an incomplete in-person examination of the Veteran and a review of the claim file and records. During the abbreviated interview, the Veteran showed symptoms consistent with PTSD, including hyperarousal symptoms (e.g., irritability). The Veteran described limitations to social functioning (i.e., a preference for isolation, difficulty maintaining social relationships, no close friends), and occupational functioning (i.e., previous termination of employment due to conflicts with supervisor). The Veteran was divorced and had a contentious relationship with his ex-wife and one of his daughters, but a good relationship with his other daughter. He had not had a romantic relationship in some time, did not have close friends, and did not belong to any social groups. The Veteran reported a longstanding history of employment difficulties due to arguing and fighting with his supervisors, as well as difficulties managing high levels of stress. He reported he had been employed as a maintenance worker at a country club for about 6 years, until February 2010, when his employment was terminated for "threatening to beat the cook down like a dog" and for being on too many psychological medications. The October 2011 VA examiner noted that an October 2007 letter from the Veteran's former country club supervisor suggested the Veteran had a long history of anger outbursts that were out of proportion to the circumstances, that would manifest physically in the form of uncontrollable shaking, voice tremor, sweating and erratic stance. The supervisor noted the Veteran performed his job at an acceptable level, but that there was no question the Veteran applied deliberate and calculated effort to control himself at all times, and though the Veteran had improved at controlling his anger outbursts, he continued to require unpaid leave at times. The October 2011 VA examiner noted the Veteran reported he had been unable to find steady work since February 2010, but continued to look. The Veteran was working with a VA Vocational Rehabilitation Specialist and was attempting to pursue temporary work as a photographer. The Veteran said he had done a half dozen photography jobs, but the stress of this work was too much for him, and he did not plan to pursue more than temporary photography work, for fear of losing his temper with a customer. The VA examiner noted that the Veteran's medical records suggested he had been hospitalized for depression and suicidal ideation in December 2008. He was taken off the Suicide High Risk list in November 2009, though he continued to endorse ongoing chronic ideation without intent at that time. During the October 2011 VA examination, the Veteran denied suicidal ideation, plan or intent. He endorsed passive thoughts of death at times, but identified his children as his primary protective factors. Finally, during the October 2011 VA examination, after describing the traumatic stressor event associated with his trauma symptoms, the Veteran suddenly became tearful and expressed anger at the examiner and the process, raised his voice and cursed, blamed the examiner for not helping him, and hurriedly left the examination room, stopping the examination. In the most recent VA examination, in January 2014, the VA examiner conducted an in-person examination, reviewed the Veteran's claim file and records and provided a thorough and detailed report. The VA examiner found that the Veteran had PTSD and bipolar disorder. She reported that the Veteran's bipolar disorder symptoms included fighting with others, depressed mood, social withdrawal, and suicidal ideation, and his PTSD symptoms included negative alterations in cognition and mood (including social detachment), and hyperarousal (including irritability/anger outbursts and hypervigilance). The VA examiner noted that, as a result of the Veteran's mental diagnoses, the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported difficulties maintaining gainful employment throughout his lifetime due to difficulties with anger outbursts, fighting, and getting along with superiors and co-workers. The Veteran discussed a strong tendency and preference to isolate socially in order to prevent further altercations with others. The Veteran's history was notable for few meaningful relationships (with family, friends, or other acquaintances). Therefore, the VA examiner stated, the Veteran's mental health disorders were considered to have a relatively significant impact on his occupational and social functioning. Nevertheless, the VA examiner noted, since the Veteran continued to be able to participate in his mental health treatment and attend classes, his diagnoses did not lead to "profound" deficiencies in most areas. The VA examiner noted that the Veteran reported few changes in his social history since the last complete VA examination in 2009. The Veteran reported that he continued to live by himself with his two dogs. When asked about current relationships, Veteran stated that he was not successful in relationships. The Veteran is divorced and reported he saw his two children once every couple of months. He denied participation or involvement in other significant social relationships, and said he prefers to spend time at home alone. The Veteran reported that he had graduated from community college in December 2013 with an Associate's Degree in Fine Arts and Photography, and started a photography business. (This program was done through a VA vocational rehabilitation program.) However, the Veteran explained that his existing, heritable condition of a resting tremor was worsened by a recent change in his PTSD and bipolar medications, so that he shakes a lot more now. The Veteran stated he was no longer able to work in photography as he couldn't produce the quality work he would like, due to his aggravated tremor. The VA examiner noted the Veteran reported that, other than his photography business, he has not worked since February 2010. The Veteran reported that, in 2010, he was working for a country club performing facility maintenance, but he threatened someone at work and subsequently lost his job. The Veteran explained he had been having problems getting along with others at work, which has been a pattern throughout his life: "I always go out in a rage." The Veteran described a long history of anger issues that have interfered with his ability to maintain successful employment. The Veteran reported that he was taking classes two times per week at the HOPE Recovery Center through the St. Louis VA. The VA examiner noted that the Veteran was actively involved in mental health care, and saw mental health care professionals regularly. The VA examiner's review of the medical notes showed the Veteran reported auditory hallucinations to one psychologist in December 2013, but that the same psychologist's January 21, 2014 notes stated that the Veteran was no longer reporting auditory hallucinations. In contrast, however, the Veteran's psychiatrist reported in a January 17, 2014 note that the Veteran reported "unremitting auditory hallucinations." The VA examiner stated that, during the January 2014 VA examination, the Veteran did not report or show any signs of auditory hallucinations. The January 2014 VA examiner noted that the Veteran's medical records showed he had been hospitalized psychiatrically in December 2008 for suicidal ideation. When asked about his current mood symptoms, the Veteran said his anger had improved in the last month because he had not been working or spending too much time around other people. The Veteran said that, with his increased medication dosages in the past two years, his manic episodes had decreased, but he had more depression and suicidal thoughts. The Veteran said that, in his lifetime, he had had too many manic episodes to count. The Veteran explained that, during manic episodes, he often has aggressive urges and has, at times, plotted to harm individuals who have upset him. For example, the Veteran reported that about a year or a year-and-a-half ago, he "plotted to hurt" a woman managing his school finances, who was "inept" at her job. The Veteran reported these urges to his mental health providers, his medications were adjusted, and the urges subsided. During the January 2014 VA examination, the Veteran directly denied any current homicidal ideation, plan or intent. The Veteran described a history of fighting at bars, and said his last physical fight was one year ago at a bar. The Veteran stated that his last significant episode of depression occurred in November/December 2013, when he was having suicidal thoughts and was considering overdosing on his medications. The Veteran described his symptoms during that episode of depression, including guilt related to the fact his trauma was from a peace time and not a combat time, becoming very tearful when he discussed this. The Veteran directly denied any current suicidal ideation, plan or intent during the January 2014 VA examination. In describing the Veteran's symptoms, the VA examiner noted that the Veteran had feelings of detachment or estrangement from others, with the Veteran describing having few friends and few interactions with his family. The Veteran also had a persistent inability to experience positive emotions, with the Veteran reporting experiencing very rare feelings of excitement and saying he didn't think he knew what love was. The VA examiner also noted the symptom of irritable behavior and angry outbursts (with little or no provocation), typically expressed in verbal or physical aggression toward people or objects. The Veteran also showed symptoms of hypervigilance, with the Veteran reporting he was very watchful, and always had situations going on in his head, for example, wondering what he would do if someone tried to knock him out. The VA examiner also reported the symptoms of depressed mood; anxiety; chronic sleep impairment; flattened affect; suicidal ideation in the past, not currently; difficulty in establishing and maintaining effective work and social relationships; the inability to establish and maintain effective relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; and impaired impulse control, such as unprovoked irritability with periods of violence. The VA examiner also noted that the Veteran had had a concussion and Traumatic Brain Injury in 2010, but that those symptoms appeared to have resolved. The VA examiner concluded that all mental health symptoms noted in the January 2014 VA examination were considered to be attributable to his PTSD and bipolar disorder, and not the result of his 2010 concussion. In his May 2012 Notice of Disagreement letter from the Veteran provides his own description of his PTSD symptoms and problems. The Veteran stated that his medication had helped, but, even with his medication, he still had mood swings, anger, rage, depression and anxiety that some days he could not control. The medication also caused light headedness and severe dizziness, and one of his doctors had told him that he shouldn't be working in the same maintenance field as he had before, because the chances were increased for a fall from ladders and heights, getting a limb caught, or falling into mechanical equipment. The Veteran discussed how his former maintenance job had brought stress, anxiety and confrontation that brought on uncontrollable anger outbursts and rage, so that others complained to management about his threats against them and sometimes even their families. The Veteran described how, with the altercations, came an overwhelming desire for revenge, and plotting for days on ways to harm the people. The Veteran would even follow them to find out where they lived. The Veteran noted that he had since started seeing a psychiatrist for this "obsession." The Veteran also explained that he had walked out on the October 2011 VA examination because he was "past the point of reason," very angry at the doctor, and didn't want to go to "the point of no return." Finally, the Veteran said his photography business had pretty much failed, and that it seemed to have been another one of his "grandiose" ideas. See May 2012 Notice of Disagreement Letter from Veteran. During his August 2017 videoconference hearing, the Veteran described his symptoms. He testified that he had panic attacks, depression, and anxiety pretty much every day, with panic attacks lasting on average hours, but sometimes a day or two. He described just having to go to bed, and having trouble with daily functioning, for example, sometimes not able to bathe, and sometimes not eating a lot. The Veteran said he had a hard time dealing with others, he felt like people "just sometimes are out to just get over on me" and he didn't feel like he could get along with people, butting heads with people all the time, which was very frustrating. Nowadays, it was all verbal, but it used to be physical. The Vet said he gets closer and gets confrontational. He gets very irritable. This could happen during stressful events, but it also happens during daily functions, like a trip to Walmart. The Veteran said he couldn't go to Walmart because the aisles are too close together and people get too close to him. He thinks they're behaving rudely, and he tends to get a little disturbed and may say something he shouldn't. The Veteran said he had been divorced twice and didn't see or talk to his children very much at all. In terms of friends, the Veteran said he had one friend that he talked to on a regular basis, and that was about it. See August 2017 Transcript of BVA Hearing. In terms of work, the Veteran stated at the hearing that he had gone to vocational rehabilitation for photography, and had tried to do a little photography work for a few months. The Veteran said he had done a few weddings, but it never amounted to anything, as the stress was little too much for him to handle. The Veteran stated he had never worked anywhere full time since 2010. The Veteran also discussed the tremor in his hands, which he said was hereditary, but had gotten worse with the medication he was on. The Veteran said some days when he gets really nervous and has panic attacks, he starts shaking really badly. See August 2017 Transcript of BVA Hearing. The Board finds that the Veteran's symptoms of PTSD with bipolar disorder have more nearly approximated the criteria for a 70 percent rating, but not higher, during the appellate period. 38 C.F.R. §§ 4.3, 4.7. In assigning a 70 percent rating for the Veteran's PTSD, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for PTSD. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran's most recent January 2014 VA examination and other records available in the claim file show that, during the appellate period, the Veteran exhibited PTSD with bipolar disorder symptoms that, at times, included suicidal ideation; 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); difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. The Board finds that the Veteran's symptoms throughout the appellate period have been consistent with and more nearly approximated occupational and social impairment with deficiencies in most areas, the criteria for a 70 percent rating. Although the medical evidence does not show symptomatology such as obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; and neglect of personal appearance and hygiene, the symptoms noted in the rating schedule are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. Mauerhan v. Principi, 16 Vet. App. 436. Thus, even though not all the listed symptoms compatible with a 70 percent rating are shown, the Board concludes that the type and degrees of symptomatology contemplated for a 70 percent rating are demonstrated during the appellate period at issue. However, the Board finds that the symptoms associated with the Veteran's PTSD with bipolar disorder do not meet the criteria for a 100 percent rating during the appellate period at issue. A 100 percent rating requires total occupational and social impairment due to certain symptoms. The Board finds that neither the delineated symptoms nor comparable symptoms are shown to be characteristic of the Veteran's PTSD with bipolar disorder. The evidence of record does not indicate that the Veteran has exhibited gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Although the medical records state that the Veteran reported experiencing auditory hallucinations for a portion of 2013, possibly stopping in January 2014, this is merely one symptom in the list of the types of symptoms contemplated for a 100 percent disability rating. Similarly, although the Veteran has at times expressed suicidal or homicidal ideation (e.g., plotting revenge), this has not been a "persistent" danger during the appellate period. In addition, although the Veteran mentioned in his Board hearing that sometimes he does not feel well enough to bathe, the vast majority of the records indicated his personal hygiene and appearance were appropriate. Moreover, throughout the record, the Veteran was consistently found to be oriented. The Veteran even socialized to a limited extent, at various times, for example, with his ex-wife, daughters, and sometimes with one friend. Therefore, he was shown to be able to be around other people, even if to a limited degree, and with some discomfort. Therefore, the Board finds that total social impairment has not been shown. In sum, the Board finds the psychiatric symptoms shown do not support the assignment of the maximum 100 percent schedular rating. 38 C.F.R. § 4.130. Accordingly, the Board finds that the criteria for a 70 percent rating, but not higher, for PTSD with bipolar disorder are met for the appellate period at issue. However, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 70 percent. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate when there is present any impairment of mind or body which is sufficient to make it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the Veteran does not meet those percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment due to service-connected disability. 38 C.F.R. § 4.16(b). In light of the assignment above of 70 percent for PTSD with bipolar disorder for the entire appellate period, the Veteran meets the minimum percentage requirements of 38 C.F.R. § 4.16(a) during the appellate period. The remaining question is whether the Veteran's service-connected PTSD with bipolar disorder caused him to be unable to secure or follow a substantially gainful occupation during the appellate period. 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 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2015); Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether a Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361. In this case, the records indicate that the Veteran has not worked since February 2010. He was reportedly terminated in February 2010 from the country club maintenance job he had held for approximately six years, because of "threatening to beat the cook down like a dog." See October 2011 VA examination. As noted above, while at his country club maintenance job and outside of it, the Veteran reportedly had repeated angry outbursts, threatened coworkers and their families, stalked people, and plotted revenge, and the Veteran felt he had barely hung on to his maintenance job over the six years, and only kept it that long because management kept changing. Since that time, the Veteran has apparently not had any substantially gainful employment. He has only done some vocational rehabilitation work through the VA, and a few photography jobs for a brief period of time, which he felt he could not continue because the photography work was too stressful, and because his PTSD/bipolar medications aggravated his existing tremor. After thoroughly considering the totality of the evidence, the Board finds that the Veteran's psychiatric symptoms have remained consistent throughout the appeal and are best described as not being able to sustain employment due to his PTSD with bipolar symptoms. The January 2014 VA examiner concluded that the Veteran's combined mental health diagnoses, to include PTSD and bipolar disorder, had a significant impact on his overall functioning. The examiner appeared to accept that Veteran's assertions that his service connected PTSD with bipolar disorder prevented him from maintaining gainful employment. In this case, the Board finds the overall evidence as to employability is at least in equipoise. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Resolving all reasonable doubt in the Veteran's favor, the Board concludes that the criteria for a TDIU are met for the entire appellate period. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a 70 percent rating, but not higher, for PTSD with bipolar disorder, is granted. Entitlement to a TDIU is granted. ____________________________________________ Lesley A. Rein Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs