Citation Nr: 18154611 Decision Date: 12/04/18 Archive Date: 11/30/18 DOCKET NO. 11-03 816 DATE: December 4, 2018 ORDER Service connection for arthritis, to include as due to exposure to herbicide agents, is denied. An initial rating in excess of 30 percent prior to February 10, 2011, for posttraumatic stress disorder (PTSD) is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Arthritis is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include as due to exposure to herbicide agents, and arthritis did not manifest within one year of service discharge. 2. Prior to February10, 2011, the Veteran’s PTSD has been productive of symptomatology resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 3. For the entire appeal period, the Veteran’s service-connected disabilities do not render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for arthritis has not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for an initial rating in excess of 30 percent prior to February 10, 2011, for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 3. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.1, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from June 1967 until April 1970. His awards and decorations include the Combat Action Ribbon. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in July 2009 and January 2014 by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2016, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In June 2016 and May 2017, the Board remanded the issues pertaining to entitlement to service connection for arthritis and entitlement to a TDIU for further development and they now return for appellate review. Additionally, the May 2017 Board decision denied an initial rating in excess of 30 percent prior to February 10, 2011, and in excess of 70 percent thereafter for PTSD, and an initial rating in excess of 30 percent prior to July 16, 2013, and in excess of 60 percent thereafter for onychomycosis of the bilateral feet. The Veteran appealed the Board’s decision only to the extent that it denied an initial rating in excess of 30 percent prior to February 10, 2011, for PTSD to the United States Court of Appeals for Veterans Claims (Court). In February 2018, the Court granted a January 2018 Joint Motion for Partial Remand that vacated the May 2017 Board decision as to such issue and the matter now returns for further appellate review. The Board notes that, following the issuance of the August 2016 supplemental statement of the case pertinent to the Veteran’s PTSD claim, additional evidence, to include updated VA treatment records, has been received. However, as such includes duplicative information of that previously considered by the Agency of Original Jurisdiction (AOJ) and/or does not pertain to such issue, no prejudice results to the Veteran in proceeding with a decision at the present time. See 38 C.F.R. § 20.1304(c). Further, as relevant to all issues, the Veteran’s representative submitted additional evidence and argument in September 2018 with a waiver of AOJ consideration. Id. Therefore, the Board may properly consider such newly received evidence. 1. Entitlement to service connection for arthritis, to include as due to exposure to herbicide agents. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. The record reflects that the Veteran is in receipt of the Combat Action Ribbon. As such, the provisions of 38 U.S.C. § 1154(b) are applicable in this case, which state, in pertinent part, that in any case where a veteran is engaged in combat during active service, lay or other evidence of service incurrence of a combat related disease or injury will be considered sufficient proof of service connection if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence during service, and, to that end, VA shall resolve every reasonable doubt in favor of the Veteran. The Federal Circuit has held that the presumption found in § 1154(b) applies not only to the potential cause of a disability, but also to whether a disability itself was incurred while in service. See Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012). The combat presumption, however, does not alleviate the requirement that the evidence show current disabilities attributable to the past in-service disorders. See generally Clyburn v. West, 12 Vet. App. 296, 303 (1999). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as arthritis, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Since the Veteran was diagnosed with arthritis of the knees prior to undergoing his knee replacements, the provisions of law governing presumptive service connection are applicable and will be addressed herein. Additionally, the law provides a presumption of service connection for certain diseases associated with exposure to herbicide agents that become manifest within a specified time period, even if there is no record of evidence of such disease during the period of service. As relevant, veterans who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, are presumed to have been exposed to herbicide agents. See 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). As the record reflects that the Veteran served in Vietnam during the requisite time period, his exposure to herbicide agents coincident with such service is presumed. Further, while certain diseases are acknowledged to be presumptively related to such exposure, arthritis is not one of them. 38 U.S.C. § 1116(a)(2); 38 C.F.R. § 3.309(e). Nonetheless, a veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this case, the Veteran contends that he has arthritis of multiple joints, most notably the low back, knees, and feet, as a result of an incident during his combat in Vietnam where he was blown 8 feet down into a bunker by an enemy artillery shell that exploded about 4 feet away from him. At the February 2016 Board hearing, he testified that the shell destroyed the bunker flash wall, and he sustained a shrapnel wound to the neck and lost consciousness at that time. The Veteran stated that he must have fallen on his shoulders and head because his helmet flew off during the incident, and he was treated by corpsmen and then returned to duty. He also contends that his arthritis is due to his exposure to acknowledged herbicide agents coincident with his service in Vietnam. The evidence of record shows that the Veteran currently has arthritis of the back, feet, and knees, to include total knee replacements. Specifically, a July 2016 VA examination report shows arthritis of back, feet, and knees, status post total knee replacements. The Veteran’s service treatment records are negative for complaints, treatment, or diagnoses referable to arthritis. However, his report of the aforementioned injury during his combat service in Vietnam is consistent with his military occupational specialty as a field artillery operator, his tour of duty in Vietnam, and the award of the Combat Action Ribbon as shown in his DD Form 214. Thus, the remaining question is whether the Veteran’s arthritis of the low back, knees, and feet, is related to his military service, to include such in-service injury and/or his acknowledged exposure to herbicide agents. In this regard, pursuant to the June 2016 Board remand, the Veteran was afforded a VA examination in July 2016; however, the Board previously determined in the May 2017 remand that the opinion rendered at such time was based upon an inaccurate factual premise and, thus, inadequate. Consequently, it will not be further discussed or considered. In accordance with the May 2017 remand, an addendum opinion addressing the etiology of the Veteran’s arthritis was obtained in October 2017. At such time, the VA examiner opined that it was less likely than not that the Veteran’s arthritis of the back, knees, and feet was related to his acknowledged herbicide exposure. In this regard, she explained that she did not find any research studies, using accepted statistical practices and analysis, which noted evidence of an association between herbicide exposure and the development of arthritis. Further, with regard to arthritis of the back, the examiner noted that the Veteran separated from service in April 1970, and went to work at a steel fabrication factory in June 1970, where he worked for 2 months. Additionally, he reported that he was employed at an office furniture manufacturer company for 30 years where he worked in assembly, the machine division, and the paint division. Furthermore, the Veteran reported that, in 1980, he received Worker’s Compensation when he tripped over a railing and fell on his back on concrete and could not get back up. He stated that he was off from work for 6 weeks for L4 back surgery, and he underwent a second back surgery, diskectomy at L5, in 1983 for removal of scar tissue and herniated disc. He also indicated that he returned to work, which included bending and lifting. The examiner further noted that the Veteran was involved in a motor vehicle accident in 2003, fell off of a roof in 2011, and had another motor vehicle accident in January 2015, at which time he reported that he sustained another concussion. Based on the foregoing, she concluded that that the Veteran’s arthritis of the back was less likely as not caused by or the result of in-service events. As rationale, the examiner explained that she did not find convincing or compelling evidence to support Veteran’s contention that an injury during military service in Vietnam caused the current multilevel degenerative changes of the lumbar spine, or was a causative factor for two surgical procedures of the lumbar spine in 1980 and 1983. She further found that the numerous traumas sustained following separation from military service, as well as working in a factory setting for 30 years, were causative factors for the development of his current lumbar spine condition. With regard to arthritis of the feet and knees, the examiner opined that such disorders were less likely as not caused by or a result of in-service events. As rationale, she explained that there was no convincing or compelling evidence to support Veteran’s contention that the injury during service in Vietnam caused the degenerative changes of the feet and severe degenerative changes of the knees, or was a causative factor for his bilateral total knee arthroplasties in 2014. She again found that numerous traumas the Veteran sustained following his separation from military service, as well as working in a factory setting for 30 years have more likely been causative factors for the development of his bilateral degenerative knee and feet disorders. The Board accords great weight to the October 2017 VA examiner’s opinion as it considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (stating that a medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions). Importantly, there is no medical opinion to the contrary. The Board also acknowledges the Veteran’s statements that his arthritis of the back, feet, and knees are related to his military service, to include the aforementioned injury during combat and his acknowledged exposure to herbicide agents. However, the Board finds that the question regarding the potential relationship between the Veteran’s current disorders and any instance of his service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, while the Veteran is competent to describe his in-service experiences and current symptomatology, the Board accords his statements regarding the causation of such disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In the instant case, the question of causation of arthritis in specific joints involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as the Veteran does not have the appropriate medical training and expertise to offer an opinion as to the etiology of his current disorders, the lay assertions in this regard have no probative value. The Board has also considered whether service connection is warranted on a presumptive basis, to include on the basis of a continuity of symptomatology. In this regard, the clinical evidence of record fails to show that the Veteran manifested arthritis to a compensable degree within the one year following his discharge from active duty service in April 1970. In this regard, the Veteran’s separation examination in April 1970 revealed that his lower extremities and back were normal upon clinical evaluation. Further, the earliest evidence demonstrating a diagnosis of arthritis of the back, feet, and knees was several years following separation from service. Consequently, while the Board has considered the Veteran’s statements regarding a continuity of symptomatology since service, the contemporaneous evidence fails to demonstrate that arthritis manifested within his first post-service year, or that his reports of pain since service have been related to a diagnosis of arthritis of the back, knees, and feet within the first post-service year. As such, presumptive service connection, to include on the basis of continuity of symptomatology, is not warranted for arthritis of the back, feet, and knees. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. Based on the foregoing, the Board finds that arthritis of the back, feet, and knees, to include total knee replacements, is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include as due to exposure to herbicide agents, and arthritis did not manifest within one year of service discharge. Therefore, service connection for such disorders is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for arthritis. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to an initial rating in excess of 30 percent prior to February 10, 2011, for PTSD. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran contends that an initial rating in excess of 30 percent for his PTSD for the period prior to February 10, 2011, is warranted due to the severity of his symptoms, to include suicidal ideation. In this regard, the appeal stems from the October 30, 2008, effective date for service connection for PTSD, to February 10, 2011, the date a 70 percent rating was assigned. Such disability is rated under the criteria of DC 9411, which provides ratings under the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130. Under DC 9411, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of 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, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted when there is 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 understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is 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; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is 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 United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation...requires an ultimate factual conclusion as to the Veteran’s level of impairment in most areas.” Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation 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). In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the general rating formula “indicates that the presence of suicidal ideation alone...may cause occupational and social impairment with deficiencies in most areas.” However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran’s service-connected psychiatric disability, and their resulting social and occupational impairment. The Board notes that the revised DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (Aug. 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, No. 16-1208 (February 23, 2018). The Board finds that an initial rating in excess of 30 percent for PTSD is not warranted for the appeal period prior to February 10, 2011, as the evidence fails to show that such disability is manifested by more severe symptomatology that results in occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. Specifically, the evidence does not establish the presence of symptoms of the type and severity necessary to warrant the next higher rating of 50 percent. In this regard, the Board finds that the Veteran’s PTSD symptoms did not result in 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 understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Regarding the Veteran’s social relationships, while he did not have a good relationship with his oldest son, he maintained a relationship with his wife for nearly 40 years and had a good relationship with his siblings and two younger sons. See April 2009 and January 2013 VA examination reports. He also attended outpatient group therapy where he felt as though he bonded with his Vietnam PTSD treatment group members. See January 2013 VA treatment report. He has been very active in outpatient based therapy since 2008 and even served as a peer/mentor for younger veterans. Id. Furthermore, during the appeal period, he reported that he enjoyed walking, bike riding, gardening, attending AA meetings, attending church, watching TV, cooking, bowling, and going to the store with his wife. See December 2008, March 2010, and June 2011 VA treatment records. Consequently, such evidence demonstrates that the Veteran maintained a fairly active social life with relationships with numerous family members and outsiders. Moreover, he formed new relationships by serving as a peer/mentor for younger veterans. Consequently, the Board finds that such reflects that his PTSD resulted in, at most, social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Turning to occupational impairment, the Veteran was employed as a postal worker since 2001, but he resigned job in approximately December 2010, which is two months prior to the February 10, 2011 date where a 70 percent rating was assigned. In this regard, prior to such date, the record reflects that the Veteran was performing his occupational tests in a fully successful manner. Furthermore, although he reported that he was forced into retirement from the post office for behavioral and attitude problems that he attributes to PTSD, there is no indication that he was ever disciplined or terminated from employment due to his PTSD symptoms. In this regard, in September 2010, it was noted that the Veteran lost his job because he failed a breathalyzer test after getting into a vehicle accident while delivering mail. See September 2010 VA treatment record. While the Veteran attributed his use of alcohol to an effort to self-medicate his PTSD symptomatology, such is not shown by the evidence of record. Rather, in December 2008, the Veteran reported that, while his PTSD symptoms resurfaced about 1.5 years previously, working lots of hours helped him to not think about them. Notably, he did not report the use of alcohol as a coping mechanism at such time, or at any point during the relevant period. See December 2008 VA treatment record. Furthermore, a March 2009 VA treatment note indicated that the Veteran’s PTSD symptoms had decreased, and in January 2013, a VA examiner indicated that the Veteran had been sober for 2.5 years so it was unlikely that his mental health symptoms were related to his history of excessive alcohol use. Furthermore, the sole fact that the Veteran had been drinking on the job, regardless of the cause, does not demonstrate that his PTSD symptomatology resulted in occupational and social impairment with reduced reliability and productivity. Furthermore, the symptoms the Veteran described during this portion of the appeal period, to include as noted by the March 2009 VA examiner (memory slightly impaired, panic attacks, flashbacks, nightmares, and impaired sleep) and their resulting impact on his social and occupational functioning are contemplated by the currently assigned 30 percent rating. In this regard, the Board is aware that the Veteran occasionally endorsed suicidal ideation during the appeal period and the Court has held that suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas. See Bankhead, supra. Specifically, the Court has noted that the language of the regulation indicates that the presence of suicidal ideation alone, that is, a veteran’s thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas. However, the Court also recognized that VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of the Veteran’s service-connected psychiatric disability. Here, the Veteran occasionally endorsed suicidal ideation, but also routinely denied intent or plan. For instance, in December 2008, he stated that he has had thoughts of suicide and attempted suicide in the past. See December 2008 VA treatment record. He also dreamed of harming himself, but declined suicidal ideation, thoughts, or plans. See February 2009 VA treatment record. Additionally, he reported suicidal thoughts three months prior when he made a mistake on his medications and took more than was prescribed because he did not feel well. See June 2009 VA treatment record. In August 2009, he reported that he had suicidal ideation a couple of weeks previously because his wife upset him, but he stated that “he realized it was stupid” and he denied any current suicidal ideation since that date. See August 2009 VA treatment record. An October 2009 VA treatment note reveals that the Veteran reported that he considered putting a gun in his mouth 4 or 5 months ago and, at the January 2013 VA examination, he indicated that he has had strong thoughts of suicide and once put a loaded gun to his head. However, the Veteran denied having any suicidal ideations shortly after his last suicidal ideation report. See November 2009, January 2010, March 2010, June 2010, September 2010, and November 2010, and June 2011 VA treatment records. Ultimately, while the Veteran did report suicidal ideation, which is contemplated under the criteria for a 70 percent rating, the Board finds that such symptomatology was not of a frequency, severity, and duration so as to result in deficiencies in most areas, or even occupational and social impairment with reduced reliability and productivity, as indicated by his ability to maintain close relationships, execute proper judgment, and maintain an appropriate mood and affect. Thus, the Board finds that the Veteran’s PTSD symptoms have not resulted in occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total social and occupational impairment during the appeal period prior to February 10, 2011. The Board has considered whether staged ratings under Fenderson supra, are appropriate for the Veteran’s service-connected PTSD; however, the Board finds that his symptomatology referable to such disability have been stable throughout the entirety of the appeal period. Therefore, assigning staged ratings for is not warranted. Further, with the exception of the raised issues of entitlement to a TDIU and special monthly compensation (SMC), neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record in connection with such claim. See Doucette v. Shulkin, 28 Vet. App. 366 (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). Therefore, based on the foregoing, the Board finds that an initial rating in excess of 30 percent for PTSD prior to February 10, 2011, is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a TDIU. The Veteran contends that he is unable to maintain substantially gainful employment due to his service-connected disabilities, to include his PTSD. As such, the appeal period stems his October 2008 date of service connection for PTSD. See Rice v. Shinseki, 22 Vet. App. 447, 452 (2009); Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc). Total disability ratings for compensation may be assigned, where the scheduler rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Rating boards should submit to the Director of Compensation Service for extra-scheduler consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16 (a). See 38 C.F.R. § 4.16 (b). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to a TDIU is based on an individual’s particular circumstances.” Rice, supra. Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering veteran’s 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering veteran’s master’s degree in education and his part-time work as a tutor). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Since October 30, 2008, the Veteran has been service-connected for PTSD, onychomycosis of the bilateral feet, degenerative disc disease of the cervical spine, tinnitus, and bilateral hearing loss, with a combined rating of 70 percent from October 30, 2008, to February 10, 2011, and 90 percent thereafter. As the Veteran’s PTSD and bilateral feet onychomycosis were service-connected as a result of his combat service in Vietnam, they may be considered as one disability under 38 C.F.R. § 4.16(a). Thus, the Veteran meets the schedular threshold criteria for consideration of a TDIU for the entirety of the appeal period. Id. However, upon review of the evidence, the Board finds that the Veteran’s service-connected disabilities did not render him unable to secure or follow a substantially gainful occupation at any point pertinent to the appeal period. In connection with his claim, the Veteran submitted a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, in April 2013, August 2013, and December 2015. In such applications, he indicated that his PTSD and skin disability of the bilateral feet prevented him from securing or following a substantially gainful occupation. He reported that he last worked in 2010 as mail carrier, but became too disabled to work in December 2010. He further indicated that he had not sought employment since he became too disabled to work and denied having any education or training beyond two years of college. However, the August 2013 application indicates that the Veteran completed peer support training in April 2013. Furthermore, the January 2013 VA examination report reveals that the Veteran completed his Associate’s Degree in Business Administration. Furthermore, VA treatment records indicate that the Veteran was a sober coach for AA in June 2011. Additionally, he was very active in outpatient-based therapy since 2008 and even served as a peer/mentor for younger veterans. See January 2013 VA treatment report. Moreover, the record indicates that he volunteered as a peer support specialist in the Vet-to-Vet program and was the primary caregiver for his wife. See October 2014 private treatment record. With respect to the impact the Veteran’s service-connected disabilities had on his ability to secure or follow a substantially gainful occupation, a January 2013 VA examiner stated that the Veteran’s skin condition of his bilateral feet impacted his ability to work because his feet itched and he was unable to work where the feet would get wet. However, a July 2013 VA examiner opined that the Veteran’s skin condition did not impact his ability to work. Rather, she noted that Veteran stated stopped working as a mail carrier due to having to get in and out of car frequently, and he was feeling overwhelmed due to PTSD symptoms. An August 2016 VA examiner opined that the Veteran’s cervical spine disability did not limit his ability to work. As rationale, she explained that he stated that he did not have work related injuries affecting his neck, knees, or feet. She further stated that the Veteran was hired as a mail carrier in December 2000, and worked there until September 2010. He reported that he did not have to walk a route, but drove in a rural area. He spent 2 hours a day standing to sort mail, and the other 6 hours delivering the mail. The examiner noted that the Veteran stated that he stopped working in 2010 due to PTSD symptoms and his drinking. However, as discussed in the preceding section, the Veteran’s PTSD resulted in, at most, occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks prior to February 10, 2011, and occupational impairment in most areas as of such date. In support of his claim, the Veteran submitted an October 2014 opinion from a national certified counselor, F.C., who indicated that the Veteran had a number of physical and cognitive issues that precluded his ability to be gainfully employed. He further explained that, while he had shown himself to be a great volunteer as a peer support specialist in the Vet-to-Vet program, he was able to set his own hours that enabled him to take care of his foot and knee issues, monitor his PTSD, and continue on the medications that supported its management. He also was the primary caregiver to his wife who has a number of medical issues that required support. He further stated that the Veteran’s anxiety worsened as he considered seeking and finding employment, and his PTSD recovery as well as the conclusion of his career at the post office left him with distrust of authority. The Veteran was certain that his bridge was burned at the post office and, in any case, he would be physically unable to perform duties required for a job there. Since that was his career, he likely lacked the needed skills for millennial occupations. Furthermore, F.C. concluded, at the Veteran’s age, it was daunting to consider starting a business. The record also contains a September 2018 private opinion from Z.F., M. Ed. In this regard, Z.F. opined that it was at least as likely as not that the Veteran was unable to secure and follow substantially gainful employment since 2010 due to his service-connected disabilities. As rationale, he explained that the Veteran’s limitations would at least as likely as not preclude his ability to perform work even in unskilled positions due to his difficulty with establishing and maintaining effective work and social relationships, difficulty in adapting to stress, unprovoked irritability with periods of violence, and memory loss. He further stated that this would lead the Veteran to be unsuccessful with completing tasks, even in an unskilled sedentary role. Z.F. referenced the Veteran’s August 2018 affidavit where he reported that his physical conditions continued to worsen since he ended his employment. In this regard, the Veteran reported that, due to his back and foot conditions, he could only stand for 10 to 15 minutes at a time before needing to sit down, and he was unable to walk for more than 10 minutes without rest. The Veteran also reported that his difficulties with communication was furthered by his bilateral hearing loss and tinnitus because he had to ask people to repeat themselves multiple times, which caused him social anxiety. The Veteran further stated that his neck condition was exacerbated by getting in and out of the vehicle to deliver mail and carry heavy packages. Notably, the question of employability is ultimately a legal one, not a medical one. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). While the January 2013 VA examiner noted that the Veteran’s service-connected onychomycosis would impact his employability by resulting in some physical limitations, those she described would not prevent or prohibit employment consistent with the Veteran’s education and work history. Specifically, she only noted that his feet itched, and he had to avoid getting them wet. Additionally, while the October 2014 and September 2018 private counselors noted that the Veteran’s service-connected disabilities resulted an inability to secure and maintain substantially gainful employment in all types of environments, such conclusions are not supported by the remainder of the record. In this regard, F.C. concluded that the Veteran had a number of physical and cognitive issues that precluded his ability to be gainfully employed; however, such conclusion was contradicted by his notation that the Veteran was a great volunteer as a peer support specialist in the Vet-to-Vet program and was the primary caregiver to his wife. Further, the difficulties that the Veteran would face in seeking or maintaining employment, as identified by F.C., included his knee disorders, an inability to return to the post office based on the circumstances surrounding his retirement, a lack of skills for millennial occupations, and his age, which are factors that are not for consideration in a TDIU determination. Specifically, the Veteran is not service-connected for his knee disorder and age may not be considered. 38 C.F.R. § 4.19. Moreover, the question is not whether the Veteran can return to his prior job, or that he is unable to do a specific job or occupation, such as a millennial occupation, but rather whether he is capable of performing the physical and mental acts required by employment. Van Hoose, supra. Consequently, as F.C. contradicted himself and considered numerous factors outside of the parameters of a TDIU claim, the probative weight of his opinion is diminished. Moreover, while Z.F. primarily found that the Veteran would be unable to work in any capacity based primarily on his PTSD symptomatology, to include his difficulty with establishing and maintaining effective work and social relationships, difficulty in adapting to stress, unprovoked irritability with periods of violence, and memory loss, the evidence of record demonstrates that the Veteran is quite capable of performing the necessary tasks of employment as demonstrated by his service as a peer counselor and sober coach, and has maintained relationships with family members and outsiders. Furthermore, while Z.F. found that the Veteran’s ability to work would also be compromised by his physical disabilities, such included consideration of the Veteran’s nonservice-connected orthopedic foot disorder and a back disorder. Moreover, Z.F. indicated that the Veteran’s bilateral hearing loss and tinnitus resulted in social anxiety; however, as noted previously, he has still demonstrated an ability to communicate effectively with people, to include maintaining and developing relationships. Finally, Z.F. did not discuss the impact of the Veteran’s cervical spine disability on his ability to work, but rather noted that such was aggravated by employment activities associated with his duties at the post office. Consequently, the probative value of Z.F.’s opinion is likewise diminished. Conversely, while the Board acknowledges that the Veteran’s service-connected disabilities result in limitations in his functioning, to include in an employment setting, a fact that is evidenced by his high schedular ratings that have been assigned during the course of the appeal, the probative evidence of the record fails to reflect that he is unable to secure or follow a substantially gainful occupation as a result of such disabilities. In this regard, as noted previously, the Veteran volunteered as a peer support specialist in the Vet-to-Vet program and he is the primary caregiver to his wife. Furthermore, he completed a certification for peer support training in April 2013, and served as a sober coach for AA. Additionally, while there may be some limitation in the Veteran’s ability to work at a job that requires him to be on his feet on a constant basis, there is no evidence to suggest that he could not work in a job that does not require extended amounts of standing or walking such as those he performs in connection with his work as a peer support specialist, sober coach, and/or caregiver to his wife. The evidence, as described and discussed above, clearly shows that the Veteran was able to maintain some level of physical activity and has training and expertise that could be valuable in the workforce, to include in a non-physical capacity such as peer support specialist. Based on the foregoing, the Board finds that the Veteran’s service-connected disabilities do not render him unable to secure or follow a substantially gainful occupation consistent with his education and work history. In this regard, while he does have some limitations associated with his onychomycosis of the bilateral feet, degenerative disc disease of the cervical spine, tinnitus, and bilateral hearing loss, and PTSD, such disabilities, alone or in combination, are not of sufficient severity to produce unemployability. As such, a TDIU is not warranted. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to SMC at the Housebound Rate. The Veteran asserts that the Board should award SMC at the housebound rate pursuant to 38 U. S.C. § 1114 (s)(1), effective July 13, 2013, based on the assignment of a TDIU based solely on PTSD and additional disability independently rated at 60 percent or more. See Akles, supra; see also Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that SMC “benefits are to be accorded when a veteran becomes eligible without need for a separate claim”); Buie v. Shinseki, 24 Vet. App. 242 (2011) (requiring the Board to consider awarding SMC at the housebound rate if a veteran meets the requisite schedular or extraschedular criteria). SMC provided by 38 U. S.C. § 1114 (s) is payable where the veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. See 38 C.F.R. § 3.350 (i). In the instant case, the Veteran is not in receipt of a single disability rated at a 100 percent, to include based on a TDIU. Therefore, SMC at the housebound rate is not warranted. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brennae L. Brooks, Associate Counsel