Citation Nr: 18155832 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 13-33 157 DATE: December 6, 2018 ORDER Entitlement to an initial disability rating of 70 percent, but no more, for service-connected dysthymic disorder is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran’s service-connected dysthymic disorder more nearly approximates manifestations of occupational and social impairment with deficiencies in most areas, but not total social and occupational impairment. 2. The Veteran has been unable to secure or follow substantially gainful employment as a result of her service-connected dysthymic disorder. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating of 70 percent, but no higher, for service-connected dysthymic disorder have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.126, 4.130, Diagnostic Code (DC) 9433 (2018). 2. The criteria for a TDIU are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.15, 4.16 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1992 to March 1995. She served in the United States Navy. A November 2016 Board hearing was held before the undersigned Veteran Law Judge (VLJ). A copy of the transcript is associated with the Veteran’s claims file. 1. Entitlement to an initial disability rating in excess of 50 percent for service-connected dysthymic disorder. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). The Veteran filed a claim for service connection for a psychiatric disorder in February 2011. The Veteran was assigned an initial disability rating of 50 percent for service-connected dysthymic disorder. To warrant a 70 percent rating, the Veteran’s psychological disorder must rise to the level of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. To warrant a 100 percent rating, the Veteran’s psychological disorder must rise to the level of 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. 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 an exhaustive list. The Board need not find all or even some of the symptoms to award a specific rating. If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002); Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). In addition, evaluation under § 4.130 is symptom-driven in that a Veteran may only qualify for a given disability rating under this criteria by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Furthermore, § 4.130 requires not only the presence of certain or similar symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013).   The Board has thoroughly reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds that an initial rating of 70 percent for service-connected dysthymic disorder is warranted. A November 2003 Emergency Department report noted that the Veteran came into the emergency room with suicidal ideations, including wanting to go to sleep and have it all go away. At the time, she also indicated that she would take her kids with her. In a November 2003 private psychiatric hospital discharge summary, it was noted that the Veteran had been admitted to the hospital because of an expression of self-harm. In a December 2004 private psychiatric evaluation, the Veteran reported having anxiety attacks in crowds, that she was tired of life, and would take her children with her if she went into the garage. A September 2005 private psychiatric evaluation note indicated that the Veteran had a very chaotic social history with significant relationship and financial problems. She was unemployed at the time and was struggling with psychosocial stressors. An October 2005 private psychiatric progress note showed that the Veteran had passive thoughts of suicidal ideation with no plan or intent. The Veteran was observed to have slow thoughts and difficult cognition, and that her insight and judgment were poor. The Veteran reported she was very angry at everybody. During a November 2005 private psychiatric evaluation, the Veteran was observed to have a flat affect, was worried, and tense. She was noted to have a difficult time concentrating and focusing, with slow speech, and found it hard to express herself. Her cognition was determined to be poor with limited insight and judgment. A January 2010 Emergency Room note showed that the Veteran reported having a constant desire to quit life, and that she felt like life was not worth living. At the time, she was suicidal with a plan. A January 2010 private psychiatric consultation note showed that the Veteran had thoughts of suicide and had a plan to take her life on Christmas eve. The note also indicated that the Veteran had prior suicide attempts in the past. A May 2010 Emergency Room note documented that the Veteran came to the emergency room because she felt like she wanted to go to her parents’ house and lock herself in the garage and die of carbon monoxide poisoning. A May 2010 private consultation note showed that the Veteran had suicidal thoughts and ideations. The Veteran expressed that she had thought of going to her parents’ house because she knew they would not be home and thought of putting her car in the garage, putting all the windows down, and letting it run. The Veteran reported that she was worried that her parents would come home to find her and therefore she did not. The physician noted that the Veteran had clearly thought it out somewhat and that the Veteran indicated that she often feels she would be better off gone. At the time, the Veteran was diagnosed with depression with suicidal ideation. In a May 2010 Behavioral Medicine note, the Veteran reported a pervasively dysphoric mood with frequent panic attacks, continued depression and contemplation of suicide, with thought and planned suicide; however, on the other hand, the Veteran stated she would never abandon her children. The Veteran was observed to have symptoms of considerable anxiety, flushing, palpitations, sense of impending doom, episodic nausea, and tremulousness, with reported panic attacks usually occurring in response to cognitive triggers. The Veteran’s thought content was positive for significant suicidal ideation, without intent. A January 2011 Behavioral Medicine note indicated that after the Veteran underwent ECT treatment, she felt more depressed, sadness, despair, hopelessness, severe fatigue, free-floating anxiety, bad sleep, poor appetite, issues with concentration, memory, and anhedonia, frequent thoughts of escaping and toyed with the idea of suicide, although she denied actual intent. In another January 2011 Behavioral Medicine note, the Veteran’s thought content was significant for suicidal ideation without active suicidal intent. She did not exhibit delusional thinking; however, she reported a recent visual illusion in which she saw a squirrel running across the ceiling. A May 2011 private social work note indicated that the Veteran continued to state that she wished she were dead. A May 2011 VA examination was conducted. The Veteran reported that she last worked in housekeeping and laundry at Heritage House and Rehabilitation Center from February 2009 to September 2010. She also reported that prior to that she worked as a substitute teacher, but could not keep up with the requirements of their daily routine and had attendance issues. The Veteran indicated that she found no enjoyment in anything, not even her own kids and that her life sucked. The Veteran stated she experienced feelings of worthlessness and hopelessness, and has felt like a failure her whole life. The Veteran acknowledged that she had suicidal ideations, but reported that she did not have intent or plan to kill herself. She stated that she had poor sleep, poor appetite, and a lack of activity due to decreased energy. The Veteran stated she wished her ex-husband would die but denied homicidal thoughts, intent, or plan. The Veteran reported panic attacks. The examiner noted that the Veteran’s unstable interpersonal relationships and longstanding, maladaptive personality traits met the criteria for a personality disorder with cluster B and dependent traits, which predated her military service. The examiner also identified depressive symptoms which was a continuation of the dysthymia diagnosed in active service. In a July 2011 Vocational report, the author noted that the Veteran has had passive suicidal ideation since 2003, and also had anxiety, chronic depression, sadness, despair, fatigue, sleep disturbances, poor concentration, and anhedonia. In a December 2012 VA Mental Health Outpatient note, the Veteran had current suicidal ideations with plan, but no intent. In a December 2012 VA Mental Health Admission Evaluation note, the Veteran was documented to have been hospitalized five times due to suicidal ideations. In a January 2013 VA Psychology Outpatient note, the Veteran reported that she had contemplated methods of suicide, including walking into thin ice and drowning, and turning on her car in the garage and breathing in the exhaust. However, she denied intent or plan to follow through. In another January 2013 VA Psychology outpatient note, the Veteran admitted she did not work very hard to meet her personal goals for hygiene and self-care. In a January 2013 VA Psychology Individual Therapy note, the Veteran was noted to continue to work toward target behaviors, such as showering, brushing teeth, and eating healthy meals. In a January 2013 VA Mental Health Treatment plan note, the Veteran reported that she felt like a ghost around her family and they hurt her feelings, that she wished she knew how to talk to her son, that she felt like a failure, and that she was experiencing housing problems. A March 2013 VA psychology outpatient note indicated the Veteran exhibited symptoms of depression, suicidal ideation, and experienced communication difficulties with her family. The Veteran reported sleep about two hours per night, spinning thoughts, and finding it difficult to concentrate. She also indicated that she struggled with self-care, such as showering and eating regularly. The Veteran indicated that she had suicidal ideation without suicidal intent, and stated that earlier in the week she had thought about running her car with the garage door closed; however, the garage door was broken in the open position. The Veteran’s suicide risk was determined to be low at the time. A September 2013 VA examination was conducted. The Veteran was diagnosed with dysthymic disorder. The examiner described the Veteran’s level of occupational and social impairment as occasional decrease in work efficiency. The Veteran reported limited interaction with her family and limited relationships overall. She reported she had one friend whom she speaks to at least weekly and felt positive about her daughter, even though she sometimes felt her daughter was too much for her because she is very clingy. However, she reported a challenging relationship with her younger son, and felt her oldest son growing more distant. The Veteran reported that she had not worked since 2010 after being terminated from her position and has not looked for work in the past few years due to her mental health concerns. The Veteran reported anxiety, not being able to trust people, and depression, which she described as triggering her suicidal ideation with planning but without intent or attempt. The examiner opined that the Veteran continued to meet the criteria for dysthymic disorder, but that the Veteran was fully employable. The examiner also believed that the Veteran’s diagnosis of personality disorder NOS contributed to a significant functional interference beyond the level accounted for by her dysthymic disorder. An October 2013 VA psychology outpatient note showed that the Veteran had chronic thoughts of death and suicide with a plan of CO2 poisoning in her garage; however, the Veteran was noted to have not made any attempts. The Veteran also denied self-injury via cutting, burning, etc., but wondered if her history of anorexia was a self-injury attempt. A March 2014 VA psychology outpatient note showed that the Veteran had longstanding hypothetical plans of overdosing or starting her car in the garage. However, she indicated that she would not act on them because she did not want to go to hell and did not want to leave her daughter. In a March 2014 VA psychology consult note, the Veteran denied having problems with appetite, weight change, olfaction, gustation, vision, coordination in the upper extremities, gait, balance, falls, and hallucinations/delusions. The Veteran’s personal care and activities of daily living were intact, and had no difficulty managing her own finances, cooking, cleaning, laundry, errands, and child care. The Veteran appeared and testified at a November 2016 Board hearing. The Veteran testified that she had really bad anxiety and had a hard time being around people. The Veteran reported that she had difficulty trusting people and communicating. The Veteran stated that when her anxiety gets really elevated, she stutters, experiences chest pains, and feels like her airways close down. She also described spinning thoughts. The Veteran stated that her anxiety attacks just come on and she would try to find a quiet place to be alone and slow her breathing. The Veteran testified that she would have panic attacks daily, although they will not always be intense daily; instead, she would experience chest pain, increased heart rate and shortness of breath. The Veteran testified that being in a stressful environment makes them worse. The Veteran reported that she did a lot of things with her church, and had friends at church, but as to her interests, she is afraid to go out there and do them. The Veteran also testified to experiencing difficulty sleeping, tangential thoughts, being overwhelmed, decreased appetite, fatigue, and thoughts of death. The Veteran described her relationship with her younger son as difficult and that she was afraid of him. A June 2018 VA examination was completed. The Veteran was diagnosed with dysthymic disorder and personality disorder-trait specified. The examiner stated that it was possible to differentiate the symptoms attributable to each diagnosis, with persistent depressive disorder to include depressed mood, poor appetite, low motivation and energy, and low self-esteem, and symptoms of personality disorder to include a history of unstable interpersonal relationships, difficulties trusting others, unstable self-image, and interpersonal hypersensitivity. The examiner described the Veteran’s level of occupational and social impairment as reduced reliability and productivity and that it would be mere speculation to try to differentiate which impairment was caused by each mental disorder. The Veteran was observed to have a depressed mood and disturbances of motivation and mood, but that she did not exhibit impairment of thought process or communication. The Veteran also denied delusions and hallucinations, and current suicidal and homicidal thoughts. The Veteran was determined to be capable of managing her own financial affairs. The examiner opined that the Veteran’s service-connected persistent depressive disorder moderately impaired her interpersonal relationships (to include co-workers and supervisors), attention and concentration, ability to cope with stress, and motivation and drive. The examiner also believed that persistent depressive disorder was at least as likely as not significantly affecting the Veteran’s reliability, productivity, and ability to follow instructions. Based on the evidence, the Board finds that a 70 percent evaluation is warranted throughout the entire period on appeal. The Veteran medical history and treatment records show that the Veteran has chronic suicidal ideations, dating as far back as 2003. The Veteran’s VA and private medical records show a history of at least five hospitalizations due to suicidal ideations. At the June 2018 VA examination, the Veteran would often get off topic when asked a question, and was somewhat difficult to redirect. At the November 2016 Board hearing, the Veteran testified that she had daily panic attacks, which affected her ability to interact with others, prevented her from going out and doing things that interests her, and caused her to avoid certain situations such going to movies because the volume is too loud. The evidence showed that the Veteran at times neglected her personal appearance and hygiene, prompting her to create target behaviors for herself such as showering, brushing her teeth, eating healthy meals. The record also showed that the Veteran had difficulty adapting to stressful circumstances (including work or a worklike setting). The Veteran testified at the November 2016 Board hearing about volunteering for her church’s food pantry and being unable to make it through a three-hour shift without asking for breaks to calm down. The Veteran also noted at the May 2011 VA examination that she had work-related issues as a substitute teacher and housekeeper because could not keep up with the requirements of their daily routine and had attendance issues. The July 2011 Vocational Report, October 2011 Mental Residual Functional Capacity Questionnaire, February 2012 Social Security Administration (SSA) Decision, and October 2016 Independent Medical Examination Report of record all attribute the Veteran’s occupational impairments as being due to psychiatrically based symptomatology, including difficulty with concentration, continued suicidal ideation, sadness and despair, depression, anxiety, issues with interpersonal relationships, attention, ability to cope with stress, and motivation and drive. These symptoms are believed to lead to increased absenteeism, inability to interact with peers and the public, and result in reduced productivity. Finally, the evidence supports the Veteran’s inability to establish and maintain effective relationships. The Veteran reported having friends at church, and one outside friend with whom she speaks with at least once a week. However, the Veteran has a difficult relationship with her family, except one sister and her own daughter, which she describes as being too much for her sometimes. The Veteran had described a growing distant relationship with her eldest son, and little to no interaction with her younger son. These findings more closely approximate social and occupational impairment with deficiencies in most areas. Resolving all doubt in favor of the Veteran, a 70 percent evaluation is warranted. However, at no time does the lay and medical evidence of record support the award of a 100 percent evaluation as the Veteran’s symptoms are not of “similar severity, frequency or duration” that cause total social and occupational impairment. Vazquez-Claudio, 713 F.3d at 118. The record does not demonstrate total social impairment because the Veteran had friends at church, and one outside friend. The record does not show that the Veteran had gross impairment in thought processes or communication, persistent delusions or hallucinations or grossly inappropriate behavior. Aside from isolated instances of being unable to express herself, inability to communicate with others due to trust issues, and one instance of seeing an illusion of a squirrel running across the ceiling, the overwhelming evidence of record shows that there is no gross impairment of thought processes or communication, persistent delusions or hallucinations, or inappropriate behavior. The evidence also shows that although the Veteran endorses chronic suicidal ideation, she is not a persistent danger of hurting herself or others, as she consistently denies intent, and cites her family and religion as reasons for not following through. She has also denied self-injurious behavior, including cutting and burning, and has sought medical help and hospitalization on at least five occasions for suicidal ideations. As for a persistent risk of hurting others, the Veteran mentioned once that she hoped her ex-husband would die, but denied homicidal thoughts, plans, and intent. The Veteran has not exhibited an inability to perform activities of daily living, or any signs that evidence disorientation to time or place, memory loss of names of close relatives, own occupation, or own name. Accordingly, a higher evaluation of 100 percent is not warranted. 2. Entitlement to TDIU VA will grant a TDIU when the evidence shows that a Veteran is precluded from obtaining or maintaining any gainful employment consistent with her education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2018). A total rating for compensation purposes may be assigned where the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155 (2014); 38 C.F.R. §§ 3.340, 3.341, 4.16(a). TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. 38 C.F.R. § 4.16 (a). The relevant issue is not whether the Veteran is unemployed or has difficulty obtaining employment, but whether the Veteran can perform the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but no consideration may be given to age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 4.16, 4.19.   Responsibility for the ultimate TDIU determination is with VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). For a Veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places him or her in a different position than other Veterans with the same disability rating. The sole fact that a Veteran is unemployed or has difficulty obtaining employment is not enough to prove unemployability. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. 38 C.F.R. §§ 3.341(a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran is only service-connected for dysthymic disorder, which is rated 70 percent disabling. The Veteran has met the schedular criteria for a TDIU for the entirety of the appeal period. For purposes of TDIU, the Veteran’s service-connected dysthymic disorder is rated 70 meets the criteria for a schedular TDIU as there was a single service-connected disability ratable at 60 percent or more. 38 C.F.R. § 4.16(a). Therefore, the remaining consideration is whether the Veteran’s service-connected disability render her unable to secure or follow substantially gainful employment. Considering the pertinent evidence in light of the above, and resolving reasonable doubt in the Veteran’s favor, the Board finds that TDIU is warranted due to the Veteran’s service-connected dysthymic disorder. In an April 2018 application for TDIU, the Veteran attributed her unemployability to her mental health issues. The Veteran was award Social Security (SSA) disability benefits in February 2012. In a January 2010 private psychotherapy nursing note, the Veteran reported that she had to leave work early because she was very tearful and lightheaded, and that she had a difficult time getting herself through work. A May 2011 Mental Disorders VA examination was conducted. At that time, the Veteran reported that she last worked in housekeeping and laundry from February 2009 to September 2010, and as a substitute teacher prior to that time. The Veteran reported that she could not keep up with the requirements of daily routine and had attendance issues. In a July 2011 Vocational Report, the Veteran was noted to have a very poor work history, with only one noted period of sustained employment from September 2001 to November 2003, when she was employed as a sales associate. Such position was classified as light duty, semi-skilled labor by the Dictionary of Occupational Titles and Its Supplements. Given the Veteran’s prior work, social, and medical history, the author of the report believed that the Veteran retained no residual functional capacity. To support the assessment, the author noted that the Veteran’s unused Bachelor’s Degree and Certificate in Teaching, along with poor evaluations and poor recommendation letters did not provide the Veteran with direct access to semi-skilled or skill labor. Moreover, the Veteran’s psychiatrically based symptomatology negates the assimilation and retention of basic work skills required at any level of employment within the national economy, further eroding her vocational and occupational base. The Veteran was also deemed to be an individual with extensive non-exertional limitations, currently precluding her from functioning independently, appropriately, effectively, socially, or on a sustained basis, and if she were to secure employment at that time, she would be unable to get through a normal workday or work week without interruptions from her psychiatrically based symptoms. The author believed that the Veteran would have a high rate of absenteeism, and difficulty with authority and interacting with peers, as well as the public. Adding to her difficulties would be her poor concentration, anhedonia, continued suicidal ideation, and overall sadness and despair, which would affect her ability to attend to a task from start to finish, and she would decompensate under even minimal stressors in any work situation. An October 2011 Mental Residual Functional Capacity Questionnaire was completed. The physician indicated that the Veteran’s mental abilities and aptitudes needed to do unskilled work ranged from seriously limited but not precluded to unable to meet competitive standards, with depression causing these problems. In a February 2012 Social Security Administration (SSA) decision, an SSA administrative law judge (ALJ) found that the Veteran had severe impairments from depression and anxiety. The ALJ also found that the Veteran had the residual functional capacity to perform unskilled light work as defined in the SSA regulations, with some exceptions. However, the ALJ ultimately found that the Veteran’s acquired job skills from prior jobs do not transfer to other occupations within the residual functional capacity as defined by SSA regulations, and in considering the Veteran’s age, education, work experience, and residual functional capacity, there were no jobs that existed in significant numbers in the national economy that the Veteran could perform. A September 2013 Mental Disorders VA examination was conducted. The examiner diagnosed the Veteran with dysthymic disorder and summarized the Veteran’s level of occupational and social impairment as occasional decrease in work efficiency. The Veteran reported that she has not worked since 2010 and had not been looking for work in the past few years due to her mental health concerns. The Veteran described symptoms including anxiety and depression, with the examiner determining that the symptoms appeared to be consistent with and similar to those described during the 2011 VA examination, including frequency and intensity. The examiner also noted depressed mood and disturbances of motivation and mood. After review of the record and examination, the examiner opined that the Veteran was fully employable, and that the Veteran’s non-service-connected personality disorder contributed to significant functional interference beyond the level accounted for by service-connected dysthymic disorder. In an October 2016 Independent Medical Examination and Report (IME Report), Dr. K.D. noted that the Veteran was diagnosed with generalized anxiety disorder and major depressive disorder secondary military sexual trauma. Dr. K.D. stated that the Veteran’s personality disorder diagnosis was not supported by the record and was rejected as inappropriate. After review of the record, testing, and observation, Dr. K.D. opined that it was his professional opinion that the Veteran had a significant occupational and social impairment due to service-connected mental illness, and that the impairment severity supported a disability rating of 100 percent due to unemployability. Dr. K.D. supported the conclusion by stating that workers with depression reported significantly more total health related lost productive time than those without depression, including absenteeism, and reduced work performance. Dr. K.D. also opined that based on the Veteran’s work history, the Veteran would not be able to perform work in the United States economy that would be more than marginal, specifically attributing significant occupational impairment to anxiety and depression. At a November 2016 Board hearing, the Veteran testified that she volunteered at a food pantry twice a week, and there had been occasions where she was left alone and could not handle the people that were coming through to choose the produce. The Veteran described having panic episodes. The Veteran further testified that each shift was a three-hour period, and she would have to take breaks and go into a dark place in the building to calm herself down. A June 2018 VA examination was conducted. The examiner noted that the Veteran had diagnoses of 1) dysthymic disorder, and 2) personality disorder-trait specified. The examiner stated that the symptoms that are the result of service-connected persistent depressive disorder included depressed mood, poor appetite, low motivation and energy, and low self-esteem, while the symptoms of the Veteran’s non-service connected personality disorder included history of unstable interpersonal relationships, difficulties trusting others, unstable self-image, and interpersonal hypersensitivity. The examiner opined that the Veteran’s occupational and social impairment was best described as reduced reliability and productivity. The Veteran reported that she filed for and was granted SSA disability benefits in February 2012 and that she has volunteered since the last VA examination, but not since the spring or summer of 2015. The examiner determined that the Veteran’s service-connected persistent depressive disorder caused moderate impairments in interpersonal relationships (to include with co-workers and supervisors), attention and concentration, coping with stress, and motivation and drive, all of which was at least as likely as not to significant affect her reliability, productivity, and ability to follow instructions. In an October 2018 letter, the Veteran’s private physician indicated that the Veteran remained disabled.   The Board recognizes some conflicting evidence of record, particularly that the Veteran was unable to continue employment due to her service connected dysthymic disorder versus non-service connected personality disorder. The September 2013 VA examiner found that the Veteran was fully employable, and that the Veteran’s non-service-connected personality disorder contributed to significant functional interference beyond the level accounted for by service-connected dysthymic disorder. However, after consideration of the record, and resolving all reasonable doubt in favor of the Veteran, the Board finds the Veteran’s service-connected disability is sufficiently disabling as to render the Veteran unable to maintain substantially gainful employment consistent with her education and occupational background. The evidence during the appeal period suggests that the Veteran’s service-connected disability rendered her unable to perform her work as a substitute teacher, even though she earned a bachelor’s degree in education and teaching certificate, or housekeeper. The evidence shows that the Veteran’s work history has been inconsistent, with only one noted period of extended employment from February 2009 to November 2010. The Veteran consistently reported that she was no longer able to work, and did not look for employment since 2010 because she was concerned about her mental health problems. An SSA ALJ also found that the Veteran had the residual functional capacity to perform unskilled light work as defined in the SSA regulations, with some exceptions. However, while the February 2012 ALJ acknowledged that the Veteran’s acquired job skills from prior jobs, the ALJ found that those skills do not transfer to other occupations and determined, after in considering the Veteran’s age, education, work experience, and residual functional capacity, that there were no jobs that existed in significant numbers in the national economy that the Veteran could perform. The October 2016 IME Report indicated a similar finding, indicating that based on the Veteran’s work history, the Veteran would not be able to perform work in the United States economy that would be more than marginal. The July 2011 Vocational Report, October 2011 Mental Residual Functional Capacity Questionnaire, February 2012 SSA Decision, and October 2016 IME Report all attribute the Veteran’s occupational impairments as being due to psychiatrically based symptomatology, including difficulty with concentration, continued suicidal ideation, sadness and despair, depression, anxiety, issues with interpersonal relationships, attention, ability to cope with stress, and motivation and drive. These symptoms are believed to lead to increased absenteeism, inability to interact with peers and the public, and result in reduced productivity. Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran’s service-connected disability render her unable to secure and follow a substantially gainful occupation. Therefore, entitlement to a TDIU is granted. 38 U.S.C. 5107; 38 C.F.R. 3.102; Gilbert, supra. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Nguyen, Associate Counsel