Citation Nr: 1803387 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 11-04 507 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent prior to April 27, 2012, in excess of 30 percent from April 27, 2012 to August 7, 2014, and in excess of 50 percent as of August 8, 2014, for an acquired psychological disorder, to include major depressive disorder (MDD) and generalized anxiety disorder (GAD). 2. Entitlement to an initial disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD), as of January 30, 2010. 3. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Eric A. Gang, Attorney ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1965 to October 1965, November 1967 to November 1969, and from May 1976 to December 1977. This matter is before the Board of Veterans' Appeals (Board) on appeal from April 2010, December 2010 and September 2011 rating decisions of the San Juan, the Commonwealth of Puerto Rico, Department of Veterans Affairs (VA) Regional Office (RO). By way of history, a September 1979 rating decision shows the Veteran was service-connected for anxiety neurosis effective November 22, 1969, rated 10 percent disabling. The Veteran was also in receipt of a 10 percent disability rating for residuals, fracture left ulna and radius. Other service-connected disabilities were rated non-compensable and the combined rating was 20 percent. In June 2005, the Veteran filed an increased rating claim and noted that his 20 percent service-connected disabilities had worsened. An October 2005 rating decision shows the Veteran's claims file was rebuilt and that the RO did not have the exact dates to establish entitlement to service connection for the issues on appeal. Additionally, the Board notes the rating decision only addressed ratings concerning the Veteran's various left arm service-connected disabilities. For reasons unknown, in November 2005, the Veteran filed a service connection claim for nervous condition. However, in a December 2005 statement, the Veteran asserted he was already service-connected for a nervous disorder and requested that his claim be processed as an increased rating claim. Thereafter, a February 2006 rating decision denied service connection for a nervous condition. In a January 2010 statement, the Veteran again notified the RO that he was already service-connected for a psychiatric disorder (identified as anxiety neurosis) and requested an increased rating. However, a December 2010 rating decision granted service connection for depressive disorder and assigned a 10 percent disability rating effective June 16, 2005; the date of his increased rating claim. The Veteran filed a timely notice of disagreement (NOD) in February 2011. The February 2011 NOD also shows the Veteran requested an effective date of September 29, 1979 for the grant of his service-connected depressive disorder. Thereafter, an October 2012 rating decision granted an increased 30 percent rating effective April 27, 2012. The October 2012 rating decision did not address the Veteran's earlier effective date claim; however, a statement of the case (SOC) was issued in December 2012 addressing both the increased rating claim for depressive disorder as well as the earlier effective date claim which was denied. The Veteran filed a timely Form 9, Substantive Appeal, that same month. A March 2015 rating decision granted an increased 50 percent rating effective August 8, 2014. Additionally, a March 2015 supplemental SOC shows the RO conceded an effective date of November 22, 1969 for depressive disorder. Additionally, the February 2016 rating decision reflects that the Veteran's depressive disorder has been rated 10 percent disabling as of November 22, 1969. Therefore, any consideration of this theory of entitlement is rendered moot. 38 U.S.C. § 7104 (2012) (no question of law or fact remaining for the Board to decide). Thus, the Board finds that the issue on appeal is more is properly characterized as an increased staged rating claim which is addressed below. The Board also notes that a March 2015 rating decision denied an increased rating for left hand carpal tunnel syndrome. In April 2015, the Veteran submitted a timely NOD. Additionally, a February 2016 rating decision denied service connection for lumbar spine disability and posttraumatic stress disorder (PTSD). The Veteran filed a timely NOD in May 2016. However, the record shows that the Agency of Original Jurisdiction (AOJ) has not issued a SOC addressing the above mentioned issues. The AOJ is clearly aware of the NODs; accordingly, those claims are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). Lastly, in September 2016, the Veteran submitted a statement asserting that benefit payments for his acquired psychological disorder stopped sometime in the 1970s. The Veteran also asserted that he did not receive an explanation as to why the payments were stopped. The Veteran requested an audit and restoration of the missing payments. Alternatively, the Veteran asserted clear and unmistakable error in any decision that had terminated his service-connected psychological disorder benefits. The record does not reflect that the AOJ has addressed this claim. Accordingly, this issue is also referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). FINDINGS OF FACT 1. As of June 16, 2005 and prior to December 9, 2014, the Veteran's acquired psychological disorder more closely approximated occupational and social impairment with reduced reliability and productivity due to symptoms including pressured speech with decreased time of response, severe anxiety, insomnia, loss of energy, irritability, diminished intellectual functions including concentration and attention, affected immediate, short term and recent memory, episodes of poor impulse control, poor stress tolerance and occasionally illogical thought content. 2. As of December 9, 2014, the Veteran's acquired psychological disorder more closely approximated occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to symptoms including suicidal ideation, spacial disorientation, minimal daily activity, frequent mood swings with easy irritability and occasional violent outbursts, near continuous anxiety and memory problems, thought content intermittently illogical, difficulty in adapting to stressful circumstances and an inability to establish and maintain effective relationships. 3. Since January 30, 2010, the Veteran's GERD was manifested by persistently recurrent epigastric distress including pyrosis, reflux, regurgitation, substernal pain, sleep disturbance and nausea four or more times per year, but these symptoms were not accompanied by dysphagia and were not productive of considerable impairment of health. 4. During the pendency of the appeal, the Veteran has been service connected for the following disabilities: depressive disorder rated 50 percent disabling effective August 8, 2014 (rated 70 percent disabling effective December 9, 2014 per this decision); non-union of styloid process of left ulna rated 30 percent disabling effective June 16, 2005; malunion and deformity of distal radius rated 30 percent disabling effective June 16, 2005; limitation of supination and/or pronation left forearm rated 20 percent disabling effective April 27, 2012; limited dorsal palmar flexion of the left wrist rated 10 percent disabling effective June 16, 2005; GERD rated 10 percent disabling effective January 30, 2010; residual scar left forearm rated 10 percent disabling effective January 30, 2010; left lateral epicondylitis rated 10 percent disabling effective April 7, 2011; left hand carpal tunnel syndrome rated 10 percent disabling effective October 8, 2013; and right wrist complex tear of the triangular fibrocartilage rated 10 percent disabling effective May 13, 2004. Prior to this decision, his combined disability rating was 90 percent from May 13, 2014. The Veteran has had a combined rating of at least 70 percent since January 30, 2010. 5. The Veteran's service-connected disabilities preclude all substantially gainful employment for which his education and occupational experience would otherwise qualify him. CONCLUSIONS OF LAW 1. The criteria for a staged rating of 50 percent, but no higher, from June 16, 2005 to December 8, 2014 for an acquired psychological disorder have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1-4.7, 4.15, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). 2. The criteria for a staged rating of 70 percent, but no higher, as of December 9, 2014 for an acquired psychological disorder have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.15, 4.21, 4.125, 4.126, 4.130, DC 9411 (2017). 3. The criteria for an initial rating in excess of 10 percent for GERD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.21, 4.114, DC 7346 (2017). 4. The criteria for a TDIU due to service-connected disabilities have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159 (2017); Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA provided the Veteran with 38 U.S.C. § 5103(a)-compliant notices in November 2005, March and July 2006, March 2010, June 2011 and September 2012. Accordingly, the record shows that VA has fulfilled its obligation to assist the Veteran in developing the claims, including with respect to VA examinations of the Veteran. Neither the Veteran nor his representative has identified any deficiency in VA's notice or assistance duties. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2017). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2017); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14 (2017); Esteban v. Brown, 6 Vet. App. 259 (1995). Acquired Psychological Disorder The Veteran's acquired psychological disorder, to include MDD and GAD is rated 10 percent disabling prior to April 27, 2012, 30 percent disabling from April 27, 2012 to August 7, 2014, and 50 percent disabling as of August 8, 2014 under DC 9411. 38 C.F.R. § 4.127 (2017). The Veteran contends that his acquired psychological disorder more closely approximates a total disability rating. 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) (2017). 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) (2017). A General Rating formula for evaluating psychiatric impairment other than eating disorders contains the actual rating criteria for rating the Veteran's disability. Pursuant to the General Rating Formula for Mental Disorders, a 10 percent rating is warranted for 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 continuous medication. A 30 percent rating is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal) due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2017). A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. 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. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. If the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (2002); Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). The Global Assessment of Functioning (GAF) score is a scale indicating the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Richard v. Brown, 9 Vet. App. 266 (1996). A score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). A score of 31 to 40 indicates there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A score of 41 to 50 indicates there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 indicates there are moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers. A score of 61 to 70 indicates mild symptoms (e.g., depressed mood and mild insomnia) or difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household). 38 C.F.R. § 4.125(a) (2017); American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). 1. Factual Background VA medical records show the Veteran began receiving VA psychiatry treatment in March 2006. The Veteran reported chronic insomnia, mood swings and persistent nightmares of war experiences even though he never served in combat. The VA psychiatrist noted the Veteran's thought content as normal and thought process as coherent, relevant and logical. The Veteran was found oriented to all spheres and his memory was found intact. His insight was noted as fair and judgement good. The Veteran was noted as clean and well groomed. His mood was euthymic and affect appropriate to content of speech. The Veteran denied having any perceptual abnormalities. The Veteran was diagnosed with depressive disorder and assigned a GAF score of 75. A June 2006 private psychiatric evaluation conducted by Dr. JZA shows the Veteran was diagnosed with GAD and PTSD and the psychiatrist assigned a GAF score of 51-60. The psychiatrist noted that he had regularly treated the Veteran since December 2005. Symptoms noted included insomnia, severe anxiety with apprehension, loss of interest in different areas of his daily life, loss of energy, sad mood most of the day, irritability, paranoia and recurrent thoughts about military experiences. The Veteran was noted to have pressured speech with a decreased time of response. His thought content was noted as logical and coherent. The psychiatrist also noted thought content associated with apprehension, paranoia and recurrent intrusive memories. No hallucinations were reported. The Veteran also denied any suicidal or homicidal ideations. His mood was noted an anxious, depressed and irritable with an intense affect. The Veteran was oriented to person, time and place. The psychiatrist also noted that the intellectual functions, including concentration and attention, were diminished. His immediate, short term and recent memory were noted as affected and remote memory was found fair. In May 2009, a VA medical record shows the Veteran reported sleep disturbances and recurrent intrusive memories. He also reported easy irritability and decreased appetite. In addition, the Veteran reported memory problems. The psychiatrist noted a neutral mood with shallow affect and anxious and depressive overtones. His speech had normal flow and was coherent. No perceptual disorder was found and the Veteran denied any suicidal or homicidal ideations. He was oriented to all spheres and presented with good judgement and fair insight. The psychiatrist diagnosed the Veteran with depression and did not assign a GAF score. In September 2009, the Veteran endorsed sleep disturbance and anxiety during the day. The Veteran also reported recurrent memories about military life. His mood was noted as neutral and affect shallow with depressive and anxious overtones. The Veteran also reported easy irritability resulting in previous conflicts with coworkers and current conflicts with his spouse. No perceptual disorder was found. Additionally, the Veteran denied any suicidal or homicidal ideations. He was oriented to all spheres; his judgement was noted as good and insight fair. No GAF score was assigned. In March 2010, a VA medical record shows the Veteran reported increased depression with frequent crying spells, anxiety, sleep impairment and feelings of worthlessness. The Veteran denied any suicidal or homicidal ideations. The psychiatrist noted the Veteran was well groomed, alert, coherent and logical. No flight of ideas or looseness of associations was found. Eye contact was fair and his attention span was noted as short. His mood was noted as very anxious and affect congruent with mood and constricted. No hallucinations or delusions were found and the Veteran's insight and judgment were noted as fair. The psychiatrist diagnosed the Veteran with depression. No GAF score was assigned Another private psychiatric evaluation was conducted in May 2010. The psychiatrist, Dr. JZA, noted the following: anxiety and apprehension almost all day; episodes of apprehensive expectations; insomnia and other sleep disturbances; irritability; poor stress tolerance; episodes of poor impulse control; loss of energy; loss of interest in almost all activities of daily living; sad mood; recurrent and intrusive thoughts; and cognitive deficits. The Veteran's speech was found pressured with decreased time of response. His thought content was found occasionally illogical but coherent with apprehension and intrusive, recurrent thought content. No hallucinations or delusions were noted. His mood was noted as anxious, depressed and irritable. His affect was intense. He was found oriented to time, person and place. His attention, concentration and intellectual functions were found diminished and his immediate, short term and recent memory were found affected. His remote memory was noted as fair. Lastly, his judgement was found poor. The psychiatrist diagnosed the Veteran with GAD, PTSD and assigned a GAF score of 51-60. A July 2010 VA medical record shows the Veteran reported poor sleep and frequent irritability. He also reported having memory problems and poor concentration. The psychiatrist noted the Veteran was well groomed, alert, coherent and logical with no flight of ideas or looseness of associations. Eye contact was fair and his attention span short. His mood was noted as very anxious and affect congruent with mood. The Veteran denied any suicidal or homicidal ideations or auditory or visual hallucinations. No delusions were elicited and his insight and judgement were noted as fair. The Veteran was diagnosed with depression. No GAF score was provided. In February 2011, the Veteran reported frequent irritability that was causing problems with his spouse. He also reported continued memory problems and poor concentration. The Veteran was diagnosed with recurrent moderate MDD and assigned a GAF score of 55-60. A May 2011 VA medical record also reflects an assigned GAF score of 55-60. The Veteran reported being dependent on his spouse for administration of his treatment. Dr. JZA issued another psychiatric evaluation in July 2011. The psychiatrist noted the Veteran presented with anxiety with apprehension almost all day with episodes of apprehensive expectation. The Veteran was also noted to have insomnia, difficulty getting to sleep with frequent dreams of military life. The Veteran was found to have difficulty concentrating. He was also found irritable with poor stress tolerance, episodes of poor impulse control, loss of energy and loss of interest in almost all activities of daily living. He was found sad most of the day with recurrent intrusive thoughts and a cognitive deficit. The Veteran's speech was noted as pressured with coherent thought content that was occasionally illogical. No hallucinations or delusions were reported. The Veteran denied any suicidal or homicidal ideations. He was found oriented to all spheres and his memory was found poor. Additionally, the Veteran's was found to have judgement poor. The psychiatrist diagnosed the Veteran with GAD with depressive mood and PTSD. A GAF score of 41-45 was assigned. An April 2012 letter from the Veteran's treating psychiatrist opined that the Veteran was totally and permanently disabled. No explanation was provided. In August 2012, a VA psychiatrist diagnosed the Veteran with recurrent moderate MDD and assigned a GAF score of 55-60. The Veteran complained of continued memory problems and poor concentration. He also endorsed sleep disturbance. The Veteran was noted as well groomed, alert, coherent and logical. No flight of ideas or looseness of associations was noted. Eye contact was fair and his attention span was noted as short. The Veteran denied any suicidal or homicidal ideations. He further denied any auditory or visual hallucinations and no delusions were elicited. His insight and judgement were found limited. A September 2012 VA medical record noted a GAF score of 55-60. The Veteran underwent a VA examination in 2012. The Veteran was diagnosed with MDD and assigned a GAF score of 65. The examiner determined that the Veteran's MDD was manifested by 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. The examiner noted symptoms of depressed mood, anxiety, trouble sleeping and lack of appetite. The examiner determined that the Veteran was able to obtain, perform and secure a financial gainful employment as his service-connected psychological disorder was "not severe enough to render him unemployable." A May 2013 VA psychiatric progress note shows the Veteran continued to report frequent episodes of irritability. He also reported frequent nightmares. He denied any suicidal or homicidal ideation. The psychiatrist noted the Veteran was well groomed, alert, coherent and logical. No flight of ideas or looseness of associations was noted. His attention span was found short and mood anxious. Affect was congruent with mood. The Veteran also denied any visual or auditory hallucinations and no delusions were elicited. His insight and judgement were found fair. The psychiatrist diagnosed the Veteran with recurrent moderate MDD and assigned a GAF score of 55-60. In February 2014, the Veteran reported continued nightmares about seeing dead people. He was noted as well groomed, alert, coherent and logical. No flight of ideas or looseness of associations was noted. The Veteran denied any suicidal or homicidal ideations. The psychiatrist noted fair eye contact, a short attention span, anxious mood and affect congruent with mood. The Veteran denied any visual or auditory hallucinations and no delusions were elicited. His insight and judgment were found limited. The psychiatrist diagnosed the Veteran with recurrent moderate MDD and assigned a GAF score of 55-60. In July 2014, the Veteran reported increased irritability which was affecting his marital relationship. He was assigned a GAF score of 55-60. The Veteran underwent another VA examination in August 2014. The examiner diagnosed the Veteran with recurrent moderate MDD with ruled-out PTSD and assigned a GAF score of 55-60. The Veteran's psychological disorder was found manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported living with his wife and that he had good family relationships. No significant interpersonal relationship difficulties were reported. The Veteran did report sleep difficulties, anxiety, nightmares, sadness, and variable irritability. The examiner noted the Veteran had adequate hygiene and was cooperative. He was alert and immediately established eye contact. No evidence of psychomotor retardation or agitation was found and his speech was clear with appropriate volume and was goal directed. His mood was labile and effect constricted at times. Additionally, there was no evidence of hallucinations or delusions. The Veteran denied any suicidal or homicidal ideations. The examiner did note recent memory difficulties with otherwise preserved cognitive functions. Insight and judgement were found superficial. The examiner noted the following symptoms: depressed mood; anxiety; chronic sleep impairment; disturbances of motivation and mood; and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner opined that the service-connected psychological disorder was not severe enough to render the Veteran unemployable. In support of this opinion, the examiner noted the Veteran's psychological disorder was chronic but mostly stable. The examiner did note that his mood instability limited his capacity to interact effectively with other individuals; thus, social functioning in a work environment involving interacting with the public, cooperative behavior with co-workers or responding appropriately to persons in authority was found limited. A December 9, 2014 private psychological evaluation noted the Veteran reported current daily activities as minimal and that he spent most of his time doing minimal household tasks. The psychiatrist noted the Veteran was appropriately dressed and that his thought content was illogical on occasion with apprehension and recurrent intrusive thoughts. The Veteran reported frequent mood swings with easy irritability. His interpersonal relations were noted as markedly limited. The psychologist noted concentration and memory problems with anxiety most of the time. The Veteran also reported nightmares and flashbacks with frequent negative thoughts and suicidal ruminations. He further reported sleep disturbances and felt hopeless and sad. The psychiatrist noted his mood as depressed and affect constricted with thinking and attitudes unmotivated and too distracted. The Veteran was noted to forget things easily. Insight and judgement were noted as poor. The psychiatrist found the Veteran's psychological disorder manifested by occupational and social impairment with deficiencies in his family relations, judgement, mood and thinking. A GAF score of 45-50 was assigned. The psychiatrist also opined that the Veteran's service-connected disabilities, standing alone, would prevent him from engaging in a gainful occupation or social environment. A March 2015 VA psychiatric progress note shows the Veteran came to an unscheduled appointment with his son. The psychiatrist noted the Veteran was disoriented and unable to identify where he was. The Veteran endorsed decreased concentration and decreased energy and motivation to do his regular activities. The Veteran's son reported the Veteran had an episode of disorientation a few days prior which had never happened previously. The psychiatrist assigned a GAF score of 55-60. Another March 2015 VA medical record noted the Veteran had poor remote memory. A November 2015 letter from a private neurologist, Dr. IAA, noted a referral was made on behalf of the Veteran's treating psychologist due to forgetfulness and memory decline. In addition, the letter noted the Veteran complained of forgetfulness and memory decline since 2005 which had worsened recently including episodes of disorientation. Following laboratory testing, brain studies and a PET, the Veteran was diagnosed with mild cognitive impairment related to his primary conditions of recurrent MDD and PTSD. The neurologist opined that the mild cognitive impairment was the most probable cause of the long-term forgetfulness and declining memory. At a January 2016 VA PTSD examination the Veteran was diagnosed with MDD which the examiner found manifested by 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. Symptoms related to the Veteran's MDD included depressed mood, mild memory loss, such as forgetting names, directions or recent events, and flattened effect. The Veteran denied current depressive symptoms, anxiety symptoms, psychotic symptoms, impulsive behavior, aggressive behavior or manic symptoms. The Veteran's speech was found coherent, relevant, logical and appropriate. The examiner observed the Veteran was alert but with mild memory problems; especially for dates. He was oriented to all spheres and his thought content was found coherent, relevant and logical. The Veteran denied any suicidal or homicidal ideations and his judgment and insight were found fair. His mood was mildly depressed with affect congruent with mood. The examiner noted no indications of a perceptual or thought disorder and the Veteran was noted to be in good contact with reality. Lastly, a July 2017 medical evaluation provided by Dr. JS opined that "due to the severity of the Veteran's symptoms and limitations, especially those associated with his in-service related injury to the left hand and arm, my medical opinion is that the Veteran would continue to be unable to perform almost any occupation even at a sedentary position." With regard to the Veteran's service-connected psychological disorder, Dr. JS found that the emotional and psychological disability would likely preclude his ability to function in an appropriate manner with other people no matter his seniority or position. Dr. JS further noted symptoms such as being easily agitated with occasional violent outbursts, social impairment with deficiencies in areas such as family and community relations, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. Lastly, Dr. JS noted unfocused concentration and attention and that the Veteran's spouse endorsed memory problems including occasionally forgetting where he was, why he left his house, and forgetting people's names or having me them. 2. Legal Analysis Initially, the Board notes that the Veteran filed an increased rating claim on June 16, 2005. The Board further notes that the Court has made it clear that there can be no free standing claim for an earlier effective date because to allow such a claim would be contrary to the principle of finality set forth in 38 U.S.C. § 7105. See Rudd v. Nicholson, 20 Vet. App. 296 (2006) (finding that only a request for revision based on CUE could result in the assignment of an effective date earlier than the date of a final decision, as free-standing claims for earlier effective dates vitiate the rule of finality). Therefore, the earliest possible effective date available for an increased evaluation for an acquired psychological disorder is June 16, 2004; one year prior to the claim for an increased rating. However, the Board notes that the first evidence of record concerning this issue on appeal is a March 2006 VA medical record. In addition, the June 2006 private psychiatric evaluation noted that the Veteran had been treated since December 2005. Thus, the record does not contain evidence that would warrant a June 16, 2004 effective date. After a review of the evidence of record, the Board concludes that a staged rating is warranted effecting all periods on appeal. Specifically, the Board concludes that prior to December 9, 2014, the Veteran's acquired psychological disorder more closely approximated a 50 percent disability rating. Thereafter, the Board concludes that the psychological disorder more closely approximated a 70 percent disability rating. The Board will first address the period on appeal prior to December 9, 2014. During this period, the Board finds the periodic private psychiatric evaluations provided by the Veteran's treating psychiatrist, Dr. JZA, the most probative evidence of record. As noted in the June 2006 evaluation report, Dr. JZA had continuously treated the Veteran since December 2005. Thus, his knowledge of the Veteran's psychological disorder was greater than the various VA examiners. The Board also notes that findings provided by the VA examiners also support findings made by Dr. JZA. Prior to December 9, 2014, the evidence of record supports a finding that the Veteran's service-connected psychological disorder more closely approximated occupational and social impairment with reduced reliability and productivity. Specifically, the June 2006, May 2010 and July 2011 private psychiatric evaluations noted similar symptoms including pressured speech with decreased time of response, severe anxiety, insomnia, loss of energy, irritability, diminished intellectual functions including concentration and attention, affected immediate, short term and recent memory, episodes of poor impulse control, poor stress tolerance and occasionally illogical thought content. VA medical records during this time period also show the Veteran reported memory problems. In addition, the Veteran reported easy irritability that had resulted in prior conflicts with coworkers and current conflicts with his spouse. GAF scores during this period on appeal most commonly reflect scores between 51-60 indicative of moderate symptoms such as flattened affect and circumstantial speech. Lastly, VA medical records dated February and May 2011 also include reports of continued memory problems, poor concentration and that the Veteran was dependent on his spouse for administration of his treatment. The Board does not find that a higher 70 percent disability rating is warranted during this period on appeal. While the 70 percent rating criteria contemplates impaired impulse control and difficulty in adapting to stressful circumstance (symptoms noted during this period on appeal) the Veteran's psychological disorder was not shown to have been manifested by suicidal ideation, illogical speech, obsessional rituals, unprovoked violence, spatial disorientation, or neglect of personal appearance and hygiene. Importantly, the Board finds that the majority of the Veteran's symptoms more closely approximated a 50 percent disability due to symptoms including flattened affect, anxiety, impairment of short term memory, impaired judgement, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Lastly, the Board additionally recognizes that the July 2011 psychiatric evaluation included a GAF score of 41-45, indicative of serious symptoms including suicidal ideation, severe obsessional rituals, frequent shoplifting, or serious impairment in social or occupational functioning. However, as noted above, those symptoms were not shown. In any event, GAF scores shortly prior to and following the July 2011 psychiatric evaluation all show scores ranging from 55-65 indicative of no more than moderate symptomatology. Thus, the Board finds that a higher 70 percent disability rating prior to December 9, 2014 is not warranted. Turning to the period on appeal as of December 9, 2014, the Board finds that a 70 percent disability rating is warranted. During this period on appeal, a December 9, 2014 private psychological evaluation demonstrates worsening symptoms, including suicidal ideation, minimal daily activity, frequent mood swings with easy irritability, markedly limited interpersonal relations, near continuous anxiety and memory problems, and thought content intermittently illogical. Moreover, the psychiatrist found the Veteran's psychological disorder manifested by occupational and social impairment with deficiencies in his family relations, judgement, mood and thinking, and assigned a GAF score of 45-50 indicative of serious symptoms. Additionally, during this period on appeal, a March 16, 2015 VA medical record shows that the Veteran reported for an unscheduled appointment with his son due to spacial disorientation. Further, a November 2015 letter from a neurologist found that the cognitive impairment related to the service-connected psychological disorder was the probable cause of the long-term forgetfulness and memory problems. Lastly, a July 2017 medical evaluation noted symptoms such as being easily agitated with sometimes violent outbursts, social impairment with deficiencies in areas such as family and community relations, difficulty in adapting to stressful circumstances and an inability to establish and maintain effective relationships. The evaluation report also noted unfocused concentration and attention and memory problems including sometimes forgetting where he was, why he left his house, remembering people's names or remembering people he met. Based on the above symptomatology, the Board finds that, as of December 9, 2014, the Veteran's psychological disorder more closely approximated occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Moreover, the 70 percent rating criteria specifically contemplates such symptoms as suicidal ideation; speech intermittently illogical; near-continuous panic attack affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. During this period on appeal, the Veteran exhibited all such symptoms. Thus, the Board finds that, as of December 9, 2014, a 70 percent disability rating is warranted. The Board does not find that a higher total 100 percent disability rating is warranted as the Veteran's psychological disorder was not manifested by gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting himself or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time, or memory loss for names of close relatives, own occupation, or own name. The Board does recognize the April 2012 letter from the Veteran's treating psychiatrist in which he opined that the Veteran was totally and permanently disabled. However, the psychiatrist offered no explanation for this opinion. In addition, it is unclear from the letter whether the psychiatrist based this assessment solely on the Veteran's psychological disorder alone or a combination of his various disabilities. Moreover, GAF scores assigned by this psychiatrist prior to and following the April 2012 letter do not support a finding of a psychological disorder manifested by total occupational and social impairment. In sum, the Board finds that, as of June 16, 2005 and prior to December 9, 2014, a 50 percent disability rating is warranted. Additionally, as of December 9, 2014, the Board finds that a 70 percent disability rating is warranted. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.130 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). GERD The April 2010 rating decision granted service connection for GERD and assigned a 10 percent disability rating effective January 30, 2010, pursuant to 38 C.F.R. § 4.114, DC 7346. As there is no Diagnostic Code for GERD, the RO has rated GERD analogous to hiatal hernia under Diagnostic Code 7346. The Board notes that when an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2017). Under DC 7346 for hiatal hernia, a 10 percent rating is warranted when the disease exhibits two or more of the symptoms for the 30 percent rating, of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, DC 7346 (2017). The Veteran underwent a VA GERD examination in March 2010. The Veteran reported suffering from recurrent stomach pain, heartburn and dyspepsia. The Veteran also reported frequent burping and abdominal pain several times per week. In addition, the Veteran reported nausea and regurgitation several times per year with occasional episodes of diarrhea. Further, the Veteran reported gnawing and/or burning pain several times per week before eating, with each episode lasting between 1 to 2 hours and relieved by antacids. The examiner noted no signs of significant weight loss, malnutrition or anemia. An X-ray study revealed a small sliding-type of hiatal hernia, gastroesophageal reflux above the carina, and acute inflammatory changes of the deudenal bulb and proximal duodenum. The Veteran was diagnosed with GERD and duodenitis. The examiner noted that the condition resulted in significant effects on the Veteran's usual occupation due to pain. A May 2010 VA medical record shows a negative gastrointestinal examination, including negative findings for dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, melena or hematochezia. The Veteran's abdomen was noted as non-tender. Negative VA gastrointestinal examinations were also reported in May and October 2010. A September 2011 VA general examination included abdomen and gastrointestinal findings. The examiner noted a history of constipation and heartburn. The examiner did not find a history of nausea, vomiting, diarrhea, indigestion, hernia, abdominal mass or swelling, regurgitation, jaundice, dysphagia, hematemesis, melena, pancreatitis, gallbladder attacks or abdominal pain. In December 2011, a VA primary care note shows the Veteran complained of reflux, a burning sensation in his epigastric area that rose, a sour taste in his mouth and gassiness. A gastrointestinal examination revealed abdominal pain and constipation. Upon examination, the physician did not find dysphagia, nausea, vomiting, hematemesis, diarrhea, melena or hematochezia. An April 2012 VA primary care record noted a negative gastrointestinal examination, including no findings for nausea, vomiting, diarrhea, indigestion, hernia, abdominal mass or swelling, regurgitation, jaundice, dysphagia, hematemesis, melena, pancreatitis, gallbladder attacks or abdominal pain. Other VA medical records show similar negative gastrointestinal examinations that occurred in September 2012, and March and August 2013. In November 2013, the Veteran's GERD was noted to recently result in oppressive dull pain in his abdomen. Pain was associated with nausea, vomiting and anxiety. The Veteran reported that he developed right flank pain with nausea and vomiting after eating lunch. A gastrointestinal examination noted nausea and one episode of vomiting. The examination did not reveal dysphagia, abdominal pain, hematemesis, diarrhea, constipation, melena or hematochezia Thereafter, negative gastrointestinal examinations occurred in April and August 2014, and April 2015. The Veteran underwent another VA examination in January 2016. The examiner diagnosed the Veteran with GERD and noted the following symptoms: persistently recurrent epigastric distress; pyrosis, reflux, regurgitation, substernal pain, sleep disturbance and nausea 4 or fewer times per year. During the examination, the Veteran reported recurrent daily acidity, heartburn, epigastric burning pain, sensation of gases, acid reflux and regurgitation of acids from his stomach. He denied vomiting but reported intermittent nausea several times per month. Symptoms were reportedly precipitated by certain food and alleviated by antacids. The examiner noted that the Veteran's condition required continuous medication. No esophageal stricture, spasm of the esophagus or an acquired diverticulum of the esophagus were found. The examiner further found that the Veteran's GERD did not impact his ability to work. Additionally, the examiner found that the service-connected GERD did not limit the Veteran from performing activities of daily living or engaging in activities of social and family life. After a review of the evidence of record, the Board finds that an initial rating in excess of 10 percent disabling is not warranted. Specifically, the Board finds that the Veteran's level of impairment does not meet the criteria for a 30 percent rating as the Veteran has never been found to have dysphagia (difficulty swallowing), nor does the evidence of record show that his GERD has been productive of considerable impairment of his health. During this period on appeal, most VA medical records noted negative gastrointestinal examination findings for any of the symptoms associated with a 30 percent disability rating. Thus, worsening symptomatology during this period on appeal appears intermittent. Significantly, medical evidence establishing worsening symptomatology, including the January 2016 VA examination report, did not find the Veteran's GERD productive of dysphagia. Lastly, as noted by the January 2016 VA examiner, the Veteran's symptoms were alleviated by antacids and the Veteran's GERD symptoms were not found to impact his ability to work or preclude him from performing activities of daily living or engaging in activities of social and family life. Thus, GERD symptoms productive of considerable impairment of the Veteran's health have not been established. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent disabling. The claim is denied. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.114 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU The Veteran filed a claim for entitlement to a TDIU in April 2011. The RO denied his claim in a September 2011 rating decision. Thereafter, the Veteran submitted additional medical evidence in the form of private medical opinions in April 2012. A SOC was issued in December 2012 and the Veteran filed a timely VA Form 9 that same month. The Veteran's claim asserts that he was unable to obtain and maintain gainful employment as a result of his service-connected disabilities. 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 as totally disabled. 38 C.F.R. § 4.16 (2017). Substantially gainful employment is that employment that is ordinarily followed by the nondisabled to earn their livelihoods with earnings common to the particular occupation in the community where the veteran resides. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment will not be considered substantially gainful employment. 38 C.F.R. § 4.16(a) (2017). The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a) (2017). The Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected condition and advancing age, which would justify a total rating based on individual unemployability due solely to the service- connected conditions. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); see also Blackburn v. Brown, 5 Vet. App. 375 (1993). The most recent February 2016 rating decision shows he was service-connected for the following disabilities: depressive disorder rated 50 percent disabling effective August 8, 2014 (now rated 50 percent disabling from June 16, 2005 to December 8, 2014, and 70 percent disabling thereafter per this decision); non-union of styloid process of left ulna rated 30 percent disabling effective June 16, 2005; malunion and deformity of distal radius rated 30 percent disabling effective June 16, 2005; limitation of supination and/or pronation left forearm rated 20 percent disabling effective April 27, 2012; limited dorsal palmar flexion of the left wrist rated 10 percent disabling effective June 16, 2005; GERD rated 10 percent disabling effective January 30, 2010; residual scar left forearm rated 10 percent disabling effective January 30, 2010; left lateral epicondylitis rated 10 percent disabling effective April 7, 2011; left hand carpal tunnel syndrome rated 10 percent disabling effective October 8, 2013; and right wrist complex tear of the triangular fibrocartilage rated 10 percent disabling effective May 13, 2004. Prior to this decision, his combined disability rating was 90 percent from May 13, 2014. The Veteran has also had a combined rating of at least 70 percent since January 30, 2010. Therefore, the remaining question is whether his service-connected disabilities preclude gainful employment for which his education and occupational experience would otherwise qualify him. An April 2012 letter from the Veteran's private physician opined that, due to the service-connected conditions involving the left hand and arm, he was unable to engage or sustain any gainful occupation. The physician further opined that the severity of the above mentioned service-connected conditions would "produce unemployability without regard to any non-service-connected disability if present." Another April 2012 letter from the Veteran's treating psychiatrist opined that the Veteran was totally and permanently disabled. No explanation was provided. In June 2015, a certified vocational evaluator (CVE) issued an independent vocational assessment opinion as to whether the Veteran's service-connected disabilities as a whole prevented him from securing and maintaining substantially gainful employment. The assessment noted the Veteran's current service-connected disabilities and their respective disability ratings. The assessment also noted review the Veteran's claims file. The CVE found that the symptoms associated with the Veteran's service-connected psychological disorder and left arm and hand disabilities alone resulted in significant vocational barriers resulting in an inability to "sustain a substantially gainful occupation even at the sedentary level of work." The evaluator noted psychological symptoms that resulted in occupational and social impairment with reduced reliability and productivity as well as diminished interest or participation in significant activities, including significant distress or impairment resulting in difficulty interacting with individuals in a social or work setting, maintaining the required pace and production demands due to an inability to concentrate on tasks, staying the scheduled amount of time and/or high absenteeism. Symptoms related to the left upper extremity included an inability to perform repetitive activity, grasping, lifting or performing finger manipulation. The CVE also noted that the left hand was essentially a helper to the right hand which had also suffered an injury that might require future surgical procedures. Given the prominence of computers in sedentary occupations, the CVE found that it was virtually impossible the Veteran would be able to use a keyboard. Thus, the CVE opined that the service-connected physical disabilities, standing alone, precluded both physical and realistic sedentary employment. In a July 2017 medical evaluation report, Dr. JS opined that "due to the severity of the Veteran's symptoms and limitations, especially those associated with his in-service related injury to the left hand and arm, my medical opinion is that [the Veteran] would continue to be unable to perform almost any occupation even at a sedentary position." Dr. JS noted that the Veteran's left hand was practically useless with strength rated a 2 on a scale to 10. The Veteran was found unable to perform repetitive activities such as grasping, lifting or performing finger manipulation. Additionally, in consideration of the Veteran's service-connected psychological disorder, Dr. JS found that the emotional and psychological disability associated with the physical injuries would likely preclude his ability to function in an appropriate manner with other people no matter the Veteran's seniority or position. In this regard, Dr. JS noted symptoms such as being easily agitated with occasional violent outbursts and social impairment with deficiencies in areas such as family and community relations. The Veteran was also noted to have difficulty in adapting to stressful circumstances and had an inability to establish and maintain effective relationships. Lastly, Dr. JS noted the Veteran suffered from memory problems as well as unfocused concentration and attention issues. Based on the above, Dr. JS opined that the Veteran would be unable to perform almost any occupation even at a sedentary position. The Board also notes that VA examiners who have conducted VA examinations of the Veteran's various service-connected disabilities all found that those disabilities were not severe enough to render the Veteran unemployable. This includes an August 2014 VA examination of the Veteran's left arm disabilities in which the examiner found that the Veteran was employable despite his service-connected left ulna and radius fracture affecting his left wrist, left forearm scar, and limitation of supination and pronation of his left forearm. Thus, given the negative VA examination reports, the Board notes that there are conflicting medical opinions of record. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The credibility and weight to be attached to these opinions is within the province of the Board. Id. In this case, the Board finds the June 2015 independent vocational assessment opinion and July 2017 medical evaluation report the most probative evidence of record. Beginning with the June 2015 independent vocational assessment opinion, the CVE determined that the Veteran was unemployable due a combination of his service-connected disabilities, and further opined that his service-connected physical disabilities, standing alone, precluded both physical and sedentary employment. In addition, the July 2017 medical evaluation report also found that the Veteran's combined service-connected disabilities precluded the Veteran from almost any occupation, even a sedentary position. Importantly, both assessments are the only evidence of record to consider the combined effect of all the Veteran's service-connected disabilities. While the August 2014 VA examiner found that the Veteran's left arm disabilities did not preclude gainful employment, no VA examination was obtained that considered the combined effects of all disabilities, including the psychological disability. Thus, the Board finds that the June 2015 independent vocational assessment and July 2017 medical evaluation report are entitled to substantial probative weight. In any event, the evidence is at least in relative equipoise with regard to whether the Veteran's service-connected disabilities preclude substantially gainful employment. In light of the above evidence and the vocational opinions of record, the weight of the evidence is in favor of a conclusion that the Veteran's service-connected disabilities prevent him from securing and following substantially gainful employment consistent with his education and occupational experience. Entitlement to a TDIU is, therefore, granted. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. § 4.16(a) (2017). (Continued on the next page) ORDER Entitlement to a 50 percent disability rating, but not higher, as of June 16, 2005 and prior to December 9, 2014, for an acquired psychological disorder, is granted subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to a 70 percent disability rating, but not higher, as of December 9, 2014, for an acquired psychological disorder is granted, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial disability rating in excess of 10 percent for GERD, as of January 30, 2010, is denied. Entitlement to a TDIU is granted, subject to the laws governing the payment of monetary benefits. ____________________________________________ Thomas H. O'Shay Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs