Citation Nr: 18151273 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 16-41 148 DATE: November 16, 2018 ORDER Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability is granted. FINDINGS OF FACT 1. The Veteran’s PTSD has been manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking, and/or mood; symptoms have not more nearly approximated total social and occupational impairment. 2. The Veteran is service-connected for PTSD, rated 70 percent disabling. 3. The Veteran’s service-connected PTSD, alone, precludes all substantially gainful employment for which his education and occupational experience would otherwise qualify him. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a TDIU due to service-connected PTSD have been met. 38 U.S.C. § 1155, 5107(b); 38 C.F.R. § 3.340, 3.341, 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1968 to July 1972. These matters come before the Board of Veterans’ Appeals (Board) from a June 2012 rating decision. I. Background The transcript of a July 1987 agency of original jurisdiction (AOJ) hearing, the reports of VA examinations dated in September 1990, April 1994, December 1995, November 2004, and August 2006, statements from the Veteran dated in March 1994, September 1995, June 2006, and December 2006, VA treatment records dated from November 1989 to June 2006, and a May 1995 letter from the United States Office of Personnel Management reflect that the Veteran completed high school and attended college on a part time basis for a couple of years. He had approximately 18 jobs in the first two years following his separation from service, including at a grocery store, as a construction worker, and as a mail clerk/building manager/groundskeeper at a hospital. His ability to perform these jobs was limited due to his PTSD, he was better able to work alone due to his temper and difficulty getting along with supervisors and coworkers, and he took significant leave from his hospital job due to psychiatric symptomatology. He medically retired from his hospital job and was awarded federal disability retirement benefits in May 1995. He was subsequently self-employed on a part-time basis (e.g. approximately 15 to 25 hours per week) doing “handyman work” and running a “hauling service”/demolition and clean up business, but he was limited in the hours he was able to work due to lack of energy, focus, and concentration and problems associated with non service-connected joint pain. The Veteran reported on a December 2009 “Veteran’s Application for Increased Compensation Based on Unemployability” form (VA Form 21-8940) that he had a high school education and that he had been a self-employed trash hauler since at least January 2005. It was becoming harder and harder for him to perform full-time employment, he had last worked on a full-time basis in 2006, and he was working approximately 15 to 20 hours per week at the time he submitted the December 2009 VA Form 21-8940. The Veteran reported during an April 2010 VA psychiatric examination that he experienced depression, nightmares, intrusive and distressing recollections of in-service trauma, psychological distress and physiological reactivity upon exposure to reminders of the trauma, efforts to avoid thoughts/feeling/conversations associated with the trauma, efforts to avoid activities/people/places that aroused recollections of the trauma, feelings of detachment or estrangement from others/social isolation, a restricted range of affect/emotional numbing, anxiety, low self-esteem, occasional suicidal ideation, impaired sleep, decreased energy, loss of interest in activities, irritability/outbursts of anger, hypervigilance, a hyperstartle response, and feelings of helplessness, hopelessness, and worthlessness. He was divorced, lived alone, had no children, was generally socially isolated, and sometimes felt lonely. Nevertheless, he had some friends/acquaintances, attended church, was making friends through volunteer activities for the homeless, and played softball 2 nights per week. He was self-employed as a trash hauler and had lost 25 weeks of work during the previous 12 months due to back pain and depression. Examination revealed that the Veteran was clean, neatly groomed, appropriately dressed, cooperative, friendly, and attentive. His speech was rapid and loud, his affect was constricted, his psychomotor activity, thought process, and thought content were all unremarkable, his mood was expansive, he was fully oriented, his memory was normal, there were no delusions or hallucinations, and his judgement and insight were normal. Also, he did not exhibit any inappropriate behavior, did not have any obsessive/ritualistic behaviors, did not experience panic attacks, was not experiencing any suicidal/homicidal ideation, had good impulse control, was able to maintain minimum personal hygiene, and did not have any problems with activities of daily living. Diagnoses of PTSD and major depression were provided. The examiner who conducted the April 2010 examination concluded that the Veteran was unable to work with others, was unable to find any work where he could work alone, and experienced increased depression, mild loss of interest, hyperarousal, intrusive thoughts and dreams, and avoidance behaviors. Hyperarousal, avoidance, and intrusive memories increased his anxiety and depression, irritability and major mood swings interfered with his social and occupational functioning, and increased symptoms reduced his ability to cope with daily stressors and lowered his self-confidence and self-esteem. The Veteran was unable to work with others, his ability to cope with stress was severely compromised, and he avoided stress as much as possible. Therefore, his functioning was artificially high on some occasions. Anxiety, depression, and PTSD symptoms negatively impacted his decisions, thought processes, and ability to work and relate to others. Moreover, the examiner explained that the Veteran was unable to work with others and that although he had tried to work alone, this was also difficult because of increased stress and PTSD symptoms. His ability to perform physical work was primarily limited by back disability, but his energy level was impacted by poor sleep. Also, his ability to concentrate on non-labor work was limited by his lack of skills because he had worked as a general laborer all his life. Overall, the Veteran was not likely to be able to maintain full-time employment in any work environment. VA treatment records dated from April to July 2010 reflect that the Veteran experienced depression, sadness, tearfulness, impaired sleep, nightmares, irritability, hypervigilance, avoidance of interpersonal contacts (outside of softball), intrusive recollections of trauma, and reduced motivation and interest. He continued to play softball and volunteer through his church, but these activities were increasingly impacted/limited by his psychiatric symptoms. His ability to maintain minimal self-employment was increasingly compromised by PTSD symptoms (e.g., avoidance and arousal symptoms). Examinations revealed that the Veteran was fully alert, oriented, and attentive, that his speech was mildly pressured, that his mood was dysphoric, and that his affect was tearful/congruent with mood. He did not experience any suicidal/homicidal ideation and his insight and judgement were normal. He was diagnosed as having PTSD and major depression. In a July 2010 letter, a VA clinical psychologist reported that he had been treating the Veteran since 1999 and that the Veteran had reported an exacerbation of his PTSD symptoms since his last evaluation in May 2010. He had some increased somatic distress (e.g., shoulder pain), but it was emotional factors that seemed to be interfering more with his work-related activities. For instance, he experienced a reduction in motivation and interest and this negatively impacted work situations and increased his social isolation/avoidance. Although he continued to attempt to be involved in some interpersonal activities (e.g., church, softball), he was much more reticent and reluctant to emotionally engage in opposite sex relationships. This suggested a further deterioration and incapacity due to PTSD symptomatology. VA treatment records dated from August 2010 to June 2011 and statements from the Veteran dated in July 2010 and March 2011 reflect that he experienced depression, anxiety, irritability, sadness, crying spells, nightmares, impaired sleep, hypervigilance, and social isolation. He continued to play softball, but this was limited by arm/shoulder pain. He still worked independently on a part-time basis cleaning out abandoned apartments and houses, but he was able to work less and less over the years and his income was declining. His annual income had decreased from approximately $21,000 in 2007 to approximately $9,000 in 2010. As of his March 2011 statement, his 2011 income was only approximately $1,100. Examinations revealed that the Veteran was fully alert, oriented, and attentive, that his speech was mildly pressured, that his mood was dysphoric/depressed, and that his affect was congruent with mood. He did not experience any suicidal/homicidal ideation, there were no signs or symptoms of a formal thought disorder, and insight and judgement were intact. The Veteran was diagnosed as having PTSD and major depression. A June 2011 VA psychiatric examination report indicates that the Veteran was divorced and maintained a relationship with his first ex-wife, but that she was returning to live in England. He played softball 3 nights per week, was involved in volunteer work (15-20 hours per week), and was involved in church activities. He had some good friends and acquaintances through these activities and he considered “these people a source of support.” He continued to operate his trash hauling business, but it was limited due to decreased demand and his physical limitations. As for psychiatric symptoms, he reported that he experienced depression, decreased energy, loss of interest in pleasurable activities, dysthymia, anhedonia, crying spells, anxiety, nervousness, tenseness, restlessness, racing thoughts, insomnia, an inability to stay focused, poor short-term memory, and feelings of helplessness, hopelessness, and worthlessness. Examination revealed that the Veteran was clean, casually dressed, cooperative, and friendly. His psychomotor activity was restless, his mood was anxious, he experienced impaired sleep, his impulse control was only fair, he had experienced aggression when provoked, and his recent and immediate memory were mildly impaired in that he reported some forgetfulness in daily functioning. As for PTSD symptoms specifically, the Veteran experienced recurrent and intrusive recollections and dreams of traumatic events in service; intense psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the events; physiological reactivity on exposure to internal or external cues that symbolized or resembled an aspect of the events; efforts to avoid thoughts, feelings, or conversations associated with the trauma; a feeling of detachment or estrangement from others; a restricted range of affect (e.g., unable to have loving feelings); impaired sleep; irritability or outbursts of anger; and a hyperstartle response. He also experienced tearfulness, social isolation, fatigue, and low energy. Moreover, the Veteran’s speech, thought process, and thought content were all unremarkable, his affect was normal, his attention and concentration were grossly intact, he was fully oriented, there were no delusions or hallucinations, his insight and judgement were normal, and he did not exhibit any inappropriate behavior. Also, he did not experience any obsessive/ritualistic behaviors, panic attacks, or homicidal/suicidal thoughts, he was able to maintain minimum personal hygiene, and he did not experience any problems with activities of daily living. The Veteran was diagnosed as having PTSD and major depressive disorder. With respect to potential employment limitations, the examiner who conducted the June 2011 VA examination explained that the Veteran was able to maintain concentration and attention for necessary periods (as evidenced by the fact that he was able to perform volunteer work and sports activities); apply common sense understanding and carry out instructions; ask simple questions or request assistance when needed; remember locations and work procedures (as evidenced by the fact that he had several contracts that required servicing different locations); make decisions based on simple sensory information; perform activities on schedule, maintain regular attendance, and be punctual within specified rules or tolerances (e.g., he worked on demand, but physical limitations restricted the amount of time that he could work); get along with coworkers or peers without becoming emotional or upset (as evidenced by the fact that he managed well with peers in sports and volunteer activities); convince or redirect others (as evidenced by the fact that he managed interactions with others in volunteer work); understand the meaning of words and use them effectively; make independent decisions or judgements based on sensory information or known guidelines (as evidenced by the fact that he provided estimates for his hauling work); and set realistic goals or make plans independently of others (as evidenced by the fact that he had run his own business for several years). Nevertheless, he was limited in his ability to complete a normal work day or week and perform at a consistent pace without excessive rest periods due to physical problems (i.e., back and wrist problems), he had a history of difficulty with supervisors, he worked better independently, and he had experienced difficulty adjusting to a recent economic downturn. Overall, the examiner concluded that the Veteran’s service-connected PTSD had not resulted in complete and total occupational and social impairment. It was not well documented that he had difficulties maintaining employment solely due to PTSD symptoms and he had capably run an independent hauling business for many years. His vocational difficulties were primarily associated with loss of contracts due to economic conditions and the limiting effect of his physical (back and wrist) problems. The examiner did note, however, that there was reduced reliability and productivity due to PTSD symptoms in that the Veteran’s anger and hypersensitivity had led to a history of confrontations with supervisors. He functioned best in a setting that permitted him to perform a job without close supervision and primarily on his own terms and schedule. He was able to sustain interpersonal contacts in his volunteer work and sports activities, but he was unable to initiate or sustain close emotional bonds necessary for a long term intimate relationship. VA treatment records dated from July 2011 to May 2012 indicate that the Veteran experienced depression, impaired sleep, nightmares, intrusive thoughts, anxiety, social avoidance, impaired concentration, irritability, and hypervigilance. He was still self-employed, but his work was limited due to a poor economy, PTSD symptoms (e.g., avoidance), and reduced physical abilities. He continued to play softball (up to 4 times a week) and engage in church and volunteer activities, but these activities were also becoming somewhat more limited. Examinations revealed that the Veteran was fully alert, oriented, and attentive, that his speech was mildly pressured, that his mood was depressed, and that his affect was congruent with mood. He did not experience any suicidal/homicidal ideation, there were no signs or symptoms of a formal thought disorder, and insight and judgement were intact. The Veteran was diagnosed as having PTSD and major depression. The Veteran reported during a May 2012 VA general medical examination and a May 2012 VA psychiatric examination that he was divorced and had various family members that he visited several times per year. He was trying to develop a relationship with his brother because they had never been very close. He was not in a relationship, but went to church and played softball 3 times a week. He had “several good close friends,” one of his friends was “more like a brother” than his own brother, he talked to his friends and visited them when he was able to get together, and he had recently attended his high school reunion. Overall, he reported that he was able to “get along with people for the most part” and did okay with friendships, but that he had been in approximately 20 relationships since his divorce in 1992 and that his relationships usually ended after a year. His days were generally spent “doing devotions,” walking his dog, volunteering with the homeless, and providing charity through his church and on his own. Overall, he spent more time volunteering than working. For instance, he ran errands with others and helped to transport others to various places. As for employment, the Veteran was still self-employed on a part time basis (one day a week) clearing apartments/homes of trash and getting them ready for renting. However, his business started declining in 2007, it had “pretty much dried up” by 2010, and he worked less and less because he was unable to work and could not afford to hire an employee. His employment was limited because the economy was limited and he experienced back and shoulder problems. He was better able to work by himself and it would be easier to work in a job that was not physically demanding. With respect to psychiatric symptomatology, the Veteran experienced crying spells; a depressed mood; anxiety; chronic sleep impairment; nightmares; intrusive recollections of trauma; psychological distress; physiological reactivity; avoidance of thoughts, conversations, activities, places, and people that reminded him of traumatic events; social isolation; low energy; poor attention and concentration; passive suicidal ideations; forgetfulness; occasional feelings of detachment or estrangement from others; a sense of a foreshortened future; irritability/anger; hypervigilance; a hyperstartle response; and impaired concentration and attention. He was fully alert and oriented, there was no evidence of any thought disorder, he did not appear to be responding to internal stimuli, there were no noted memory deficits, his fund of knowledge, insight, and judgment were all adequate, and he was not experiencing any homicidal/suicidal ideations at the time of the examination. A diagnosis of PTSD was provided. The examiner who conducted the May 2012 psychiatric examination concluded that the Veteran’s psychiatric disability resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although he generally functioned satisfactorily, with normal routine behavior, self-care, and conversation. Moreover, the May 2012 examiner opined that there were no psychological reasons why the Veteran would not be able to obtain or maintain employment. He played softball three times a week, was active in his church, volunteered with the homeless, and helped others in his neighborhood with various errands and tasks. He worked when he was able to get a job cleaning up locations being prepared for rental, but he did report physical problems that interfered with his ability to work. In a March 2013 statement, the Veteran reported that he worked for 22 different employers from 1972 to 1995. During that time, he experienced verbal and physical confrontations with other employees because of stress and depression. His longest period of employment was at a hospital, but he worked in four different departments at that job, his employer had made adjustments to accommodate his disabilities, and he medically retired from his hospital job. He subsequently attempted to run his own business hauling trash and fashioned his job such that he could work for himself, by himself, and with minimal contact with other people. His contact with customers was limited to discussing the price and materials to be hauled away. Over time, he began to experience problems with thinking and concentrating and he had a few confrontations with customers that were caused by stress and depression. He was able to stop working during the day and go home or skip work altogether on days that he was more stressed and depressed, but this was only because he was his own boss. Although he had lost some business due to the economy, he had also lost some business or decided not to take on additional business due to his psychiatric disability and work had become more difficult over time. As a result, he was unable to secure and maintain substantially gainful employment. As for recreational activities outside of work (e.g. softball and volunteer work), the Veteran noted that he was experiencing more stress and depression and did not have any true friends. He attempted to be courteous to people, but he was never comfortable around other people in any situation and occasionally yelled at others when he could no longer hold his feelings inside. VA treatment records dated from January 2014 to July 2016 indicate that the Veteran experienced depression, sadness, anxiety, irritability, impaired sleep, nightmares, tearfulness, intrusive thoughts, impaired concentration and focus, poor motivation, and hypervigilance. He maintained long distance relationships with his brother and mother, but he otherwise had limited interpersonal connections. He experienced significant emotional detachment due to PTSD, and this negatively impacted his ability to establish relationships. He continued to attend church, but he had switched churches and was unable to initiate close relationships at the new church. He also remained involved with softball and volunteering. His employment was limited by his physical difficulties and the local economy. Also, the nature of his PTSD symptoms (e.g., social isolation, arousal symptoms) prevented him from seeking other, less isolative jobs. Examinations revealed that the Veteran was fully oriented and attentive and that his energy level was normal. His mood was depressed/anxious with periods of irritability, his affect was congruent with mood, his speech was occasionally pressured, and his insight was occasionally only fair. He did not experience any suicidal/homicidal ideation, hallucinations, or delusions, there were no signs or symptoms of formal thought disorder, and judgment was normal. The Veteran was diagnosed as having PTSD and major depression. The report of a VA psychiatric examination dated in July 2016 indicates that the Veteran reported that he completed high school and a few semesters at community college. Prior to service, he worked at a movie theater and a grocery store. After service, he worked at approximately 20 jobs (e.g., in construction, in a warehouse) from 1972 to 1980 because he was unable to maintain a job due to mental health symptoms and altercations with other people. He subsequently worked at a hospital (in housekeeping, in the mailroom) from 1980 to 1995. Since 1995, he had been self-employed and operated a hauling business. He had also been involved in community service at a soup kitchen for the previous 8 years. As for psychiatric symptoms, he experienced impaired sleep; nightmares; hypervigilance; a hyperstartle response; mistrust of others; anxiety; lack of motivation (including an occasional lack of motivation to wake up, brush his teeth, and shower); impaired concentration; recurrent, involuntary, and intrusive distressing memories of traumatic events; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with traumatic events; a persistent negative emotional state; feelings of detachment or estrangement from others; a persistent inability to experience positive emotions; suspiciousness; mild memory loss; disturbances of motivation and mood; and an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Examination revealed that the Veteran was well-groomed and dressed, cooperative, compliant, and fully oriented. His speech was loud, fast, and circumstantial, he appeared anxious, he moved around in his seat, and his eye contact was fleeting. He did not appear to pose any threat of danger or injury to himself or others. The Veteran was diagnosed as having PTSD. The examiner who conducted the July 2016 examination concluded that this disability resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking, and/or mood. In August 2016, the psychologist who conducted the July 2016 VA examination explained that the Veteran’s anxiety caused him to have difficulty performing well under pressure. His suspiciousness resulted in interpersonal difficulties with supervisors, co-workers, and customers. His sleep impairment and irritability caused him to be short-tempered in a work environment, his mild memory loss was an impairment when performing general tasks in the workplace, and his circumstantial thinking and speech caused him to have poor communication skills. Also, his weak motivation resulted in delayed completion of work requirements. VA treatment records dated from September 2016 to June 2017 indicate that the Veteran experienced depression, sadness, impaired sleep, irritability, and social isolation. He remained involved in softball and volunteer activities. Examinations revealed that he was appropriately dressed and groomed with good hygiene, pleasant, cooperative, and fully oriented. His mood was depressed/euthymic/anxious, his affect was congruent with mood, and his speech was occasionally pressured. He did not experience any suicidal/homicidal ideation, hallucinations, or delusions, there were no signs or symptoms of formal thought disorder, and insight and judgment were normal. Diagnoses of PTSD and major depression were provided. In a July 2017 report, vocational specialist C.A. Young M.A., C.R.C. reported, in pertinent part, that the Veteran had no job skills that arose out of his work history. Therefore, he was restricted to unskilled work. Unskilled work, by its very nature, is characterized by close supervision and a regimented production pace, or at least an expectation of sustained output. The Veteran was incapable of either of these tasks. He did run a “business” where he worked a low level, was not supervised, and did not have any production expectations. In other words, he could take as much time as he wanted. He had earned approximately $5,000 during the previous few years. This condition does not exist for unskilled employees in the national labor force. In addition, the Veteran’s symptomatology limited his ability to handle stress or focus for the length of time required to perform even routine, non-intellectually demanding work. He had a serious problem working around or for others. Although he did perform some volunteer work, he could do this on his own terms without receiving orders or deadlines. In other words, the volunteering was more of a hobby, rather than a structured employment situation. The Veteran had always tried to work, but he was unable to work and there was sufficient documentation to show that he is below the threshold or ability to engage in any unskilled substantial employment. Therefore, the vocational specialist opined that it was likely (“as likely as not”) that the Veteran was unable to secure or follow a gainful occupation as a result of his service-connected disability. In particular, symptoms such as difficulty in adapting to work or a work like environment, lack of impulse control, lack of judgement, and difficulties in acting independently precluded work, even at the unskilled level. Any work that exists in the national economy that at least exists at the national poverty level or above was out of the Veteran’s reach, and he was restricted to odd jobs here and there. A September 2017 VA PTSD Disability Benefits Questionnaire (DBQ) reflects that the Veteran experienced recurrent, involuntary, and intrusive distressing memories of traumatic events; recurrent distressing dreams in which the content and/or affect of the dream was related to the traumatic events; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events; avoidance of or efforts to avoid external reminders that aroused distressing memories, thoughts, or feelings about or closely associated with the traumatic events; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; hypervigilance; an exaggerated startle response; problems with concentration; and sleep disturbance. He also experienced anxiety; suspiciousness; mild memory loss; circumstantial, circumlocutory, or stereotyped speech; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances (including work or a work like setting); and impaired impulse control. Examination revealed that the Veteran was well groomed, cooperative, and fully oriented. He was anxious and had circumstantial speech. He did not experience any suicidal/homicidal ideation or psychosis, and he did not appear to pose any threat of danger or injury to himself or others. The Veteran was diagnosed as having PTSD. The psychologist who completed the DBQ indicated that this disability resulted in occupational and social impairment with reduced reliability and productivity. II. Analysis A. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). As a preliminary matter, the Board notes that following an August 2016 statement of the case (SOC), additional relevant evidence was associated with the Veteran’s claims file (including VA treatment records and the September 2017 DBQ). In an October 2017 statement, the Veteran’s representative indicated that the Veteran did not request “AOJ review of any evidence not previously considered by the AOJ.” The Board considers this statement to be a waiver of initial AOJ consideration of the additional relevant evidence associated with the claims file since the August 2016 SOC. In this regard, a remand of the psychiatric issue on appeal for the issuance of a supplemental statement of the case would merely delay resolution of the claim with no benefit flowing to the Veteran. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (noting that “[a] veteran’s interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution”). Entitlement to a rating in excess of 70 percent for PTSD The Veteran’s PTSD is rated under 38 C.F.R. § 4.130, DC 9411. The criteria for rating psychiatric disabilities other than eating disorders are set forth in a General Rating Formula for Mental Disorders (General Rating Formula). See 38 C.F.R. § 4.130. Under the General Rating Formula, 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 work like setting); and an 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 form 8behavior; 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; and 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. On the other hand, 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. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). The Board notes, parenthetically, that VA updated its regulations to incorporate, in lieu of the DSM-IV, references to the Fifth Edition of the DSM (DSM-5) which, among other things, eliminates Global Assessment of Functioning scores. These changes apply to claims that were certified for appeal to the Board on or after August 4, 2014. See 80 Fed. Reg. 14,308 (March 19, 2015) (Applicability Date). In this case, the DSM-5 is applicable. See September 2016 “Certification of Appeal” form (VA Form 8). Initially, the Board notes that the Veteran has been diagnosed as having non-service-connected psychiatric disabilities other than PTSD during the claim period, including major depression. However, where an examiner is unable to distinguish the symptoms of a service-connected disability from non-service connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)). In this case, the Board finds that the symptoms of the Veteran’s service-connected PTSD cannot be clearly distinguished from those of his other diagnosed nonservice-connected psychiatric disabilities. Therefore, the Board will attribute all of the Veteran’s psychiatric symptoms to PTSD for the purposes of assessing the severity of that disability. See Id. The Veteran contends that a rating in excess of 70 percent is warranted for his service-connected PTSD. Considering the pertinent evidence in light of the applicable rating criteria and considerations, the Board finds that the Veteran’s PTSD has not met or approximated the criteria for a rating higher than 70 percent at any time during the claim period. The Board acknowledges that the Veteran has not been gainfully employed during much of the claim period, that there is evidence of occupational impairment due to his service-connected psychiatric disability, and that the evidence indicates that he is unable to secure and follow gainful employment due to his psychiatric disability. Hence, the Board concedes that there has been total occupational impairment due solely to the Veteran’s psychiatric disability during the claim period. Regardless of the Veteran’s total occupational impairment, however, there has not been total social impairment. Although he lives alone and his social interactions have been limited due to his psychiatric disability, he nonetheless has maintained relationships (albeit somewhat impaired relationships) with family members. In addition, he has consistently been involved with playing softball and participating in volunteer activities during the claim period, and he has made friends and/or acquaintances associated with these activities. Furthermore, the Veteran has experienced some impaired memory and concentration, nightmares, intrusive thoughts, and occasional suicidal ideation. Nevertheless, he has not generally demonstrated gross impairment in thought processes or communication, there have been no hallucinations or delusions, he has been pleasant and cooperative with all examiners and has not exhibited any grossly inappropriate behavior during the claim period, he has not experienced memory loss for names of close relatives, own occupation, or name, he has remained fully oriented to time and place during the claim period, and he has generally been able to perform activities of daily living. While there is some evidence of occasional suicidal ideation during the claim period, suicidal ideation is contemplated by a 70 percent rating under the General Rating Formula. In addition, although the Veteran has reported an occasional lack of motivation to maintain personal hygiene and the July 2016 VA examination report notes an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), the Veteran has consistently been appropriately dressed and groomed with good hygiene during his evaluations throughout the claim period. Overall, he has not exhibited most of the symptoms indicative of a 100 percent rating under the General Rating Formula, and the overall level of impairment has not more nearly approximated total social impairment during the claim period. In sum, the Board finds that, overall, the Veteran has not exhibited most of the symptoms listed in the criteria for the maximum, 100 percent rating under the General Rating Formula as examples of the type and extent, frequency or severity, as appropriate, to indicate both total social and occupational impairment at any point during the claim period. Moreover, his level of impairment has not more nearly approximated total social impairment. Rather, the Veteran’s psychiatric symptoms and overall level of impairment have most closely approximated the criteria for a 70 percent rating under the General Rating Formula during the entire claim period. Hence, a rating in excess of 70 percent for PTSD is not warranted. The Board further finds that, in conjunction with the claim for an increased rating for PTSD, other than the matter of the Veteran’s entitlement to a TDIU (which is addressed below), neither the Veteran nor his representative has raised any other related issues, nor have any other such 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). B. TDIU Where the schedular rating is less than total, a TDIU may be assigned when it is found that a veteran is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16 (a). 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 condition. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); see also Blackburn v. Brown, 5 Vet. App. 375 (1993). Marginal employment shall not be considered substantially gainful employment. Marginal employment generally shall be deemed to exist when a veteran’s earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16 (a). Entitlement to a TDIU due to service-connected disability The Board finds, for the following reasons, that the Veteran’s service-connected PTSD, alone, precludes all substantially gainful employment for which his education and occupational experience would otherwise qualify him. The Veteran is only service-connected for PTSD, rated 70 percent disabling. Hence, he meets the percentage requirements for a TDIU. See Id. The remaining question is whether his service-connected PTSD, alone, precludes gainful employment for which his education and occupational experience would otherwise qualify him. In this regard, the Board finds that the Veteran only partially completed some college education and that he spent much of his full-time career working at a hospital in housekeeping, maintenance, and the mail room. During this time, he experienced significant occupational impairment due to symptoms associated with his psychiatric disability (e.g., mood problems and an inability to get along with supervisors and co-workers). As a result, he medically retired from his hospital job and was awarded federal disability retirement benefits in May 1995. Since that time, he has been self-employed and has run a junk hauling business. He was only able to perform this job because it allowed him to work on his own, without any supervision, according to his own schedule, and without any significant interaction with others (with the exception of occasional interactions with customers). In other words, this job was performed in a protected environment. Although this occupation was substantially gainful for a period of time, he has not worked on a full-time basis since approximately 2006, his ability to perform this job has become increasingly limited due to both psychiatric symptoms (e.g. mood problems, lack of motivation, and impaired concentration and memory) and physical impairments, and this employment is no longer gainful. Also, the vocational specialist who provided the July 2017 opinion indicated that the Veteran is unable to secure or follow a gainful occupation solely as a result of his service-connected psychiatric disability While there are some medical opinions that the Veteran’s service-connected psychiatric disability, alone, does not preclude all substantially gainful employment, medical examiners are only responsible for providing a full description of the effects of disability upon a veteran’s ordinary activity. See 38 C.F.R. 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013)). The ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one, but is rather a determination for the adjudicator. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). The above discussion of the severity of the symptoms of the Veteran’s service-connected psychiatric disability and his educational and occupational experience, to include the medical opinions, reflects that the preponderance of the evidence is in favor of a conclusion that the Veteran is unable to secure and follow substantially gainful employment as a result of his service-connected psychiatric disability. Hence, entitlement to a TDIU is warranted. 38 U.S.C. 5107 (b); 38 C.F.R. 3.102. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Elwood, Counsel