Citation Nr: 18147123 Decision Date: 11/02/18 Archive Date: 11/02/18 DOCKET NO. 08-12 238 DATE: November 2, 2018 ORDER Entitlement to service connection for sleep apnea is denied. A rating of 70 percent for posttraumatic stress disorder (PTSD) from August 15, 2006 through September 13, 2008, is granted, subject to the applicable law governing the award of monetary benefits. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU) is granted, subject to the applicable law governing the award of monetary benefits. FINDINGS OF FACT 1. Sleep apnea did not have onset during active service, was not caused by active service, and was not caused or aggravated by service-connected disability. 2. For the entire period on appeal, the Veteran’s PTSD was productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, but not total social and occupational impairment. 3. The most probative evidence of record demonstrates that the Veteran was precluded from substantially gainful employment, consistent with his education and occupational experience, as a result of his service-connected left knee, right knee, and lumbar spine disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.303, 3.310 (2018). 2. From August 15, 2006 through September 13, 2008, the criteria for an evaluation of 70 percent, but no higher, are met. 38 U.S.C. §§ 1155, 5103, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (DC) 9411 (2018). 3. The criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1968 to July 1970, with service in Vietnam. He died in April 2012. The appellant is the Veteran's surviving spouse and has been substituted as the claimant for the purposes of all claims that were pending on the date of the Veteran's death. Upon receipt of the Veteran's August 15, 2007 claim, a November 2007 rating decision denied a rating in excess of 30 percent for PTSD. In a November 2009 rating decision, the RO increased the rating assigned for PTSD to 70 percent, effective September 14, 2009. In August 2011, the Board granted a disability rating of 50 percent for PTSD prior to September 14, 2009, and denied a disability rating in excess of 70 percent as of September 14, 2009. In November 2013 the Board denied a rating in excess of 50 percent for PTSD prior to September 14, 2008, and granted a disability rating of 70 percent for PTSD from September 14, 2008, to September 14, 2009. The appellant timely appealed this decision to the Court. In June 2014, pursuant to a Joint Motion for Remand (Joint Motion), the Court vacated and remanded the Board’s November 2013 decision to the extent that it denied a disability rating for PTSD in excess of 50 percent prior to September 14, 2008. The Joint Motion explicitly stated that it did not disturb the Board’s November 2013 determination that the Veteran was entitled to a 70 percent rating from September 14, 2008, to September 14, 2009. In September 2014 the Board denied a rating in excess of 50 percent prior to September 14, 2008, for PTSD. The appellant appealed the September 2014 Board decision to the United States Court of Appeals for Veterans Claims (Court). In December 2015 the Court issued a memorandum decision that vacated the September 2014 Board decision. A July 2016 Board decision remanded the claim for development that included obtaining a VA medical opinion. Duties to Notify and Assist Neither the appellant nor her attorney 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 a duty to assist argument). The Board also finds that there has been compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection for Sleep Apnea Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2018). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service- the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2018). In addition, service connection for certain chronic diseases may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2018); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2018); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Secondary service connection may be granted for a disability, which is proximately due to, the result of, or aggravated by, an established service-connected disorder. 38 C.F.R. § 3.310 (2017); Allen v. Brown, 7 Vet. App. 439 (1995). VA is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran’s military records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). The appellant asserts that the Veteran had sleep apnea related to his service or his service-connected PTSD. The Veteran’s service treatment records (STRs) contain no complaints or findings related to a sleep disorder. The Veteran specifically denied having any sleep problems on the July 1970 Report of Medical History report completed near the time of his separation from service. The first mentions of sleep difficulties of record are contained in an October 1993 VA PTSD examination. Post-service treatment records associated with the claims file note a diagnosis of sleep apnea in April 2007. A VA medical opinion was obtained in May 2016. The examiner noted a review of the claims file. The physician opined that the Veteran’s sleep apnea was not related to service, noting that the Veteran had not been shown to have sleep apnea until some 35 years after service and had denied having any sleep problems upon his separation from service. The physician also opined that it was less likely than not that the Veteran’s sleep apnea was related to or aggravated by his service-connected PTSD, noting that the weight of the current medical literature did not support such a link. In support of the opinion, the examiner physician conducted a detailed medical records review and referenced pertinent medical literature. The Board finds that service connection for sleep apnea is not warranted. First, there is a current diagnosis of sleep apnea. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). Second, the Board finds that there was not an in-service injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The STRs are negative for any sleep disability during service and there is no medical evidence showing onset therein or within one year. Thus, there are no findings of a chronic condition during service, and there is no diagnosis within one year of service. Any assertions by the appellant or the Veteran that sleep apnea symptoms began during service and continued over the years are found competent but not credible, as the Veteran denied such problems at the time of his service discharge. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Thus, service connection cannot be presumed on either basis. See 38 C.F.R. §§ 3.307, 3.309. Third, the Board finds that the evidence of record does not support a finding that sleep apnea is related to service or to a service-connected disability. The Board finds that the May 2016 VA opinion is of great probative value. The opinion contains a comprehensive review of the Veteran’s medical records and lay statements and offered a well-reasoned explanation for the opinion provided. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting the central issue in determining probative value is whether the examiner was informed of the relevant facts in rendering a medical opinion). Additionally, there is no evidence of sleep difficulties until 1993, and there is no medical evidence of sleep apnea until 2007, almost over 35 years after service discharge. This weighs against a finding that it is otherwise related to service. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of disorder). The appellant and the Veteran have asserted that the Veteran's sleep apnea is related to service or is secondary to his service-connected PTSD. But the Board finds that these etiological opinions are not capable of lay observation and are thus not competent. Respiratory disorders are complex internal conditions, as opposed to a disorder that is capable of lay observation such as ringing in the ears or varicose veins. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007) (holding that varicose veins are capable of lay observation and thus lay testimony may serve to establish a diagnosis); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (lay testimony may establish the presence of tinnitus because ringing in the ears is capable of lay observation). Moreover, any such opinion is outweighed by the probative May 2016 VA opinion. Accordingly, the most probative evidence of record indicates that sleep apnea is not related to service. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Rating in excess of 50 percent prior to September 14, 2008 for PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155, 38 C.F.R. § 4.1 (2018). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2018). After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2018). The Veteran’s PTSD has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under that diagnostic code, a 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, due to such symptoms as: suicidal ideations; 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); and the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. However, the symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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 rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). “[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms shall have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio, 713 F.3d 112. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126. In addition, the evaluation must be 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. Psychiatric examinations frequently included assignment of a Global Assessment of Functioning (GAF) score. The Board notes that the GAF scale was removed from the more recent DSM-V for several reasons, including its conceptual lack of clarity, and questionable psychometrics in routine practice. See DSM-V, Introduction, The Multiaxial System (2013). This appeal arises from the Veteran's August 15, 2007 claim for an increased rating for PTSD. As noted, the relevant time period for consideration is the time period one year before the claim was filed. In a September 2007 treatment note, the Veteran denied experiencing depression or memory loss, but he endorsed having trouble sleeping. In a separate September 2007 depression screen, the Veteran indicated that he experienced the following symptoms nearly every day: little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, and trouble concentrating on things. The Veteran stated that he had not experienced a poor appetite or overeating. The Veteran on several days had felt badly about himself, thought that he would be better off dead, and had thoughts of hurting himself. The Veteran denied moving or speaking slowly or feelings of restlessness. In October 2007, the appellant reported that the Veteran would disappear when friends or family members came around, and this behavior was worsening. The appellant stated that the Veteran would become angry during conversations, and he would then pout for days. The appellant stated that the Veteran had violent nightmares during which he appeared to be fighting. The Veteran occasionally awakened sweating, moaning, and screaming, and he was often unable to return to sleep. The appellant often had to sleep in a different room because she feared for her safety. The appellant stated that the Veteran sat in a bedroom all day and disconnected himself from everyone. The appellant reported that the Veteran's inability to hold a job caused severe stress on their marriage and their ability to meet financial obligations. The Veteran underwent a VA examination in October 2007. The Veteran experienced worsening dreams about Vietnam multiple times weekly. Medication helped the Veteran fall asleep, but he did not always stay asleep. The Veteran reported that he did not want to be around others because he did not trust people and felt uncomfortable. Instead, the Veteran preferred to be alone and felt comfortable by himself. The Veteran primarily watched television. The Veteran felt easily irritated, and he indicated that he was mean to the appellant. The Veteran felt sad most of the time, and he often thought of Vietnam, but he avoided war movies and books. The Veteran did not have close friends and did not feel close to anyone. The Veteran previously attended counseling, but he did not go often because he did not feel it was helpful. The Veteran denied suicidal or homicidal ideation. The Veteran reported that he had been married to the appellant for 37 years, and they had two children. The Veteran and the appellant lived with their daughter, and the Veteran had frequent contact with his son. The Veteran indicated that he did not have friends and did not go to church. The Veteran stated that he and the appellant went out to eat about once a month, but he did not otherwise participate in other social activities. The Veteran denied a legal history. The Veteran arrived on time for the interview, and he was clean, well-groomed, and oriented to all spheres. The Veteran's demeanor was approachable and he was appropriate throughout the examination. The Veteran's affect was flat and his voice level and speech were within normal limits. The Veteran's thought processes were grossly intact and goal-directed, the Veteran's contact with reality was sound with no visual or auditory hallucinations, and there was no evidence of memory impairment. The Veteran could manage all levels of self-care and activities of daily living. The examiner's impression was that the Veteran's symptoms had worsened but that it was difficult to detect because his affect was so flat and blunted. The examiner assigned a GAF score of 52. Under the heading "effect of PTSD on occupational and social functioning," the examiner reported that the Veteran's occupational and social functioning were moderately to severely impaired, depending on the day and circumstances. In June 2008, the Veteran's son, LM, stated that the Veteran was occasionally irritable. LM had never felt physically threatened by his father. LM reported that the Veteran's memory had deteriorated over the past ten years, including forgetting the names of family members and life-long friends. LM also indicated that the Veteran did not sleep on a regular schedule. In an October 2008 depression screen, the Veteran responded "not at all" to the questions concerning how often during the previous two weeks he had experienced little interest or pleasure in doing things or felt down, depressed, or hopeless. The Veteran underwent a VA examination in September 2009. The examiner noted that the Veteran's electronic records showed PTSD and depression on his problem list, and the Veteran was currently taking sertaline, which caused the Veteran to feel drowsy. The examiner observed no notes, however, relating to mental health treatment. The Veteran had not received outpatient treatment for a mental disorder, and he had not been hospitalized for a mental disorder. The Veteran indicated that he had experienced symptoms over the past year, and that he also received current treatment. The Veteran had not undergone group therapy or individual psychotherapy, and the Veteran reported that the medication did not help. The Veteran reported that he felt "somewhat" depressed, and as if he did not have a purpose in his life. The Veteran had thoughts of harming himself, but denied suicidal plan or intent. The Veteran endorsed feeling worthless, helpless, and hopeless. The Veteran's sleep was reportedly poor; the Veteran reported experiencing 3 to 5 hours of sleep nightly, depending on whether he had nightmares. The Veteran reported that he struggled to initiate and maintain sleep, and he did not feel rested upon waking. The Veteran felt tired, and his energy level and motivation were both low. The Veteran stated that he did not want to do anything, "just watch TV and stay away from everyone." The Veteran had no libido. The Veteran felt occasionally angry and struggled with decision-making, noting that he often changed his mind. He felt anger towards his wife. The Veteran managed his hygiene every couple of days. The Veteran reported feeling depressed, and he most often found himself thinking about Vietnam. The Veteran had been married to his wife for 39 years, and he described the relationship as "fair," noting that he treated his wife "kind of bad." The Veteran indicated that he physically struck his wife in December 2008 while under the influence of alcohol. This event was not his first episode of violence with his wife, but it had otherwise been several years since he physically assaulted her. The Veteran had two children; he indicated that he was not "real close" with them. The Veteran indicated that he and his wife lived with his daughter. The Veteran spoke with his son once every two weeks by phone. The Veteran had eight living siblings, but he did not speak with them. The Veteran indicated that he watched television and took care of his daughter's dog. Once every couple months, he and his daughter would go out to eat. The Veteran was socially detached and his impulse control was limited when under the influence of alcohol. The Veteran was not involved in any activities. Upon examination, the Veteran was clean, neatly groomed, and appropriately and casually dressed. Psychomotor activity was unremarkable and speech was spontaneous, clear and coherent. The Veteran's attitude was cooperative and attentive, his affect was congruent, and his mood was anxious. He was unable to perform serial sevens, but was able to spell a word forward and backward. The Veteran was oriented to person, time and place, and his thought process was linear. The Veteran's thought content was unremarkable, and there were no delusions. The Veteran understood the outcome of behavior, understood that he had a problem, and was of average intelligence. The examiner noted that sleep deprivation interfered with concentration and focus but that the Veteran was still able to accomplish tasks sometimes. There were no hallucinations, inappropriate behavior, or obsessive ritualistic behavior, and the Veteran interpreted proverbs appropriately. There were no panic attacks or homicidal thoughts and suicidal thoughts were noted before. The Veteran had fair impulse control, with the examiner noting episodes of domestic violence towards the Appellant. The Veteran maintained minimum personal hygiene and had no problems with household chores, toileting, grooming, shopping, self-feeding, bathing, and dressing, but he had slight problems with driving due to road rage and aggressive driving. The Veteran's remote, recent, and immediate memory were all normal. Symptoms of PTSD included recurrent and intrusive recollections of the event; persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness demonstrated by markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted range of affect, and sense of foreshortened future; and persistent symptoms of increased arousal by difficulty falling or staying asleep, irritability or outbursts of anger, and hypervigilance. A GAF score of 48 was assigned. The examiner noted changes in the Veteran's functional status and quality of life since the last examination included performance in employment (that is, the Veteran did not get along with co-workers or supervisors, but instead "put up with them"), family role functioning (that is, the Veteran hit his wife and had no relationships with siblings), interpersonal relationships (no friends or acquaintances), and recreation (limited to watching TV, taking care of his daughter's dog, and occasionally dining out). PTSD was responsible for the Veteran's loss of impulse control due to angry outbursts and his lack of friends and close connections with family due to social detachment, lack of trust in others, and reduced participation in recreational activities. The Veteran's prognosis with treatment was fair to good but without it was guarded. The examiner reported that there was not total occupational and social impairment due to PTSD signs and symptoms, but the signs and symptoms of PTSD did result in deficiencies in judgment (hit his wife while under the influence of alcohol in December 2008); thinking (poor concentration and memory); family relations (hit his wife; no relationships with siblings); work (did not get along with co-workers and supervisors when he did work); and mood (depressed). As for the time period prior to September 2008, the Board's November 2013 decision found that the Veteran's PTSD was productive of two symptoms required for a 70 percent rating, 1) depression occasionally affecting the Veteran's ability to function effectively, and 2) difficulty adapting to stressful circumstances. The Board's September 2014 decision found that the Veteran's PTSD symptoms included depression, sleep disturbances, isolative behavior, anger, flattened affect, and thoughts of self-harm. Although not always stated in overt terms, the Court's December 2015 Memorandum decision essentially found that the Veteran's PTSD symptoms during this appeal period included limited impulse control, suicidal ideation, violent behavior towards his wife and others, hyperstartle reaction, preoccupation with service, avoidance of military stimuli, and inability to remember the names of family members and lifelong friends. The Court's December 2015 Memorandum decision also found that the Veteran had occupational difficulties stemming from “problems with anger, working with authority figures, and depression." Further, the December 2015 Memorandum decision also stated that the Veteran frequently quit jobs because of PTSD symptoms, including irritability, short-temperedness, depression, and an inability to get along with supervisors and coworkers, and cited to the April 2005 VA examination and October 2007 VA examination reports for support of such findings. An additional symptom noted by the Court was deficiencies in judgment as demonstrated by violent behavior, including towards his wife. After reviewing the pertinent evidence of record, the Board finds that the evidence warrants a rating of 70 percent for PTSD for this time period. As discussed, symptoms such as deficiencies in judgment and mood have been noted, and some suicidal ideation and impaired impulse control has been demonstrated. Depression affecting the Veteran’s ability to function effectively and difficulty adapting to stressful circumstances have been shown alongside the Veteran's isolative behavior. Employment problems arising from the Veteran's anger and depression have been noted by the Veteran, his wife, and VA examiners. Based on the foregoing, and while acknowledging that not all the symptoms listed for a 70 percent rating have been met, the Board finds that a rating of 70 percent for PTSD from August 15, 2006 through September 14, 2008, is warranted. The Board observes that the evidence does not demonstrate total social and occupational impairment. The Veteran was able to maintain his marriage (albeit with difficulties) and he had frequent contact with his daughter and son. The Board finds that this does not equate to total social impairment. Additionally, there are not symptoms due to PTSD such as gross impairment in thought processes or communication. While some memory and concentration problems have been noted, no gross impairment in thinking or communication was suggested by any of the examiners. Although acts of violence to others have been noted, there has not been a pattern of grossly inappropriate behavior. Further, disorientation to time or place, or just minimal hygiene, has not been shown. Based on the foregoing, a rating in excess of 70 percent for PTSD is not warranted. The Board finds that there is not such an approximate balance of the positive evidence and the negative evidence to permit an even more favorable determination. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Neither the appellant nor her attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). TDIU Entitlement to a TDIU requires evidence of service-connected disability so severe that it is impossible for the veteran in particular, or an average person in general, to follow a substantially gainful occupation. 38 U.S.C. § 1155, 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. VA regulations indicate that when a veteran’s schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned when: 1) if there is only one disability, this disability shall be ratable at 60 percent or more; and 2) if there are two or more disabilities, at least one disability shall be ratable at 40 percent or more, and there must be sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). In addition to the foregoing, there must be evidence that the disabled person is unable to secure or follow a substantially gainful occupation. Id. Marginal employment is not considered substantially gainful employment. Id. A total disability rating may also be assigned pursuant to the procedures set forth in 38 C.F.R. § 4.16 (b) for veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). The Veteran’s service-connected disabilities were PTSD, rated as 70 percent disabling, duodenal ulcer, rated as 10 percent disabling, tinnitus, rated as 10 percent disabling, right hand shell fragment wound, rated noncompensable, venereal warts, rated noncompensable, and left hand shell fragment wound, rated noncompensable; the combined service-connected disability rating was 80 percent. As the Veteran had two or more disabilities, with at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more, the Veteran satisfied the percentage rating standards. The question now becomes whether the Veteran was precluded from substantially gainful employment, consistent with his education and occupational experience, as a result of his service-connected disabilities. In a September 2009 claim, the Veteran indicated he last worked full time in 2007 as a shuttle bus driver. He also indicated that he worked one day in March 2009. He further reported that he had completed high school and had no college. The Veteran had indicated in statements and various records that after service he had worked as an engine mechanics and had obtained a commercial driver’s license. The Veteran claimed that he had held over 20 different mechanic jobs during his career as he had difficulty getting along with coworkers and supervisors. Following a review of the Veteran's claims file, in May 2018 a VA psychologist stated that the Veteran's PTSD had been productive of impairments in most areas such as thinking, judgement, and relationships. The VA psychologist then stated that it was likely that the Veteran's PTSD symptoms would have impacted his ability to function in an occupational environment. It was further noted that the Veteran would have likely functioned adequately if working independently with a flexible schedule. A private July 2018 vocational assessment prepared by JC, noted that the Veteran's wife had indicated that the Veteran had stopped working in August 2007 as a bus driver because he felt as though his PTSD rendered him unable to continue working. The Veteran had briefly returned to work in 2009 as a means to “get out of the house,” but this work attempt failed due to his PTSD symptoms. It was noted that the Veteran did not earn substantially gainful wages since 2006. JC stated that there were no jobs performed in isolation and that employers would not tolerate decreased productivity on an ongoing and routine basis. As such, JC disagreed with the May 2018 VA psychologist and opined that the Veteran had been more likely than not unable to secure and follow substantially gainful employment due to his PTSD from August 2007 to April 2012. In particular, JC noted that the Veteran had likely been unable to sustain concentration and focus to complete work tasks, unable to interact appropriately with others in a workplace setting, and unable to attend a regular work schedule consistent with the demands of competitive employment. The Board finds that the Veteran was precluded from substantially gainful employment, consistent with his education and occupational experience, as a result of his service-connected PTSD and other disabilities. The Veteran’s employment in recent years has consisted mostly as a shuttle bus driver, and it is clear that his service-connected PTSD symptoms such as being unable to sustain concentration, being unable to interact appropriately with others, and being unable to maintain a regular work schedule likely precluded such work. While acknowledging that the May 2018 VA psychologist noted that the Veteran would have likely functioned adequately if working independently with a flexible schedule, the Board finds that JC's contrary opinion is essentially supported by comments from the 2005 and 2007 VA examiners. For example, the April 2005 VA examiner had noted that since 1999 the Veteran had frequently quit jobs because of PTSD symptoms, including irritability, short-temperedness, depression, and an inability to get along with supervisors and coworkers. The October 2007 VA examination report had referenced the Veteran's statement that he had “quit a total of 25 jobs” because he would get "fed up" with jobs and get into arguments at work and that there had been times when he woke up feeling depressed and would call in sick or not show up for work. Based on the foregoing, entitlement to TDIU is warranted. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD David Nelson