Citation Nr: 18156310 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 10-14 498 DATE: December 7, 2018 ORDER The appeal for a rating for posttraumatic stress disorder (PTSD) greater than 30 percent prior to September 9, 2010 and greater than 50 percent thereafter, is denied. A 70 percent rating, but no higher, for PTSD is granted, effective September 9, 2010. A total disability rating for individual unemployability (TDIU) due to service-connected disabilities from January 20, 2010 is granted, subject to the laws and regulations governing payment of monetary benefits. FINDINGS OF FACT 1. For the period prior to September 9, 2010, the Veteran’s PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: anger, irritability, anxiety, mild memory loss, depression, and sleep impairment. 2. For the period from September 9, 2010, the Veteran’s PTSD was manifested by occupational and social impairment in most areas due to such symptoms as: suicidal thoughts, impairment in judgment, thinking, mood, family relations, severe depression, anxiety, suspiciousness, panic attacks more than once a week, nightmares two to three times per week, irritability, restricted affect, sense of foreshortened future, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control. 3. Since January 20, 2010, the Veteran was unable to obtain or maintain substantially gainful employment due to his combined service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating for PTSD greater than 30 percent prior to September 9, 2010 are not met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2018). 2. Resolving reasonable doubt in the Veteran’s favor, the criteria for a rating for PTSD of 70 percent, but no higher, are met from September 9, 2010. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2018). 3. Resolving reasonable doubt in the Veteran’s favor, the criteria for a TDIU from January 20, 2010 are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.3, 4.15, 4.16, 4.18, 4.19, 4.25 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1983 to August 1984. The Board previously remanded the appeal in January 2012 and April 2017 for further development. As noted by the Board in its April 2017 remand, the Veteran had previously been awarded a TDIU effective from January 20, 2010 to September 9, 2010. However, in a May 2016 rating decision, the agency of original jurisdiction (AOJ) changed the January 20, 2010 date to May 24, 2010 based on their finding of clear and unmistakable error. In that decision, the AOJ also set an earlier effective date for the award of special monthly compensation (SMC) at the housebound rate. See 38 U.S.C. § 1114; 38 C.F.R. § 3.350(i). Because this rate is in effect from that date, the TDIU issue is moot from May 24, 2010 to the present. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008); DVA Sum. Op. Gen. Counsel Prec., 75 Fed. Reg. 11229-04 (Mar. 10, 2010) (withdrawing VAOPGCPREC 6-99, 64 Fed. Reg. 52375 (1999)). The only issue that remains is whether a TDIU is warranted prior to May 24, 2010, which the Board will address below. Entitlement to a rating for PTSD greater than 30 percent prior to September 9, 2010 and greater than 50 percent thereafter. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating 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. 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. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Thus, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a “staged rating” (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). The Veteran’s service-connected psychiatric disabilities are rated under Diagnostic Code 9411. Under the rating schedule, a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130. 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 for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; 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. 38 C.F.R. § 4.130, DC 9411. 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. 38 C.F.R. § 4.130, DC 9411. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). When evaluating a psychiatric disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall 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. Id. However, when evaluating the level of disability from a psychiatric disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126 (b). As reiterated by the U.S. Court of Appeals for Veterans Claims (Court) in Bankhead v. Shulkin, 29 Vet. App. 10, 18 (2017), “VA must engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran’s service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment.” In this case, the Veteran was assigned an initial disability rating of 30 percent for his PTSD. In September 2008, he filed a claim for an increased rating. In March 2009, the AOJ continued the 30 percent rating and the Veteran appealed the decision. During the pendency of the appeal, in April 2011, the AOJ increased the rating to 50 percent from September 9, 2010. The Veteran seeks higher ratings for both periods on appeal. During the period prior to September 9, 2010, the Veteran was provided a VA examination in October 2008. His subjective reports as well as objective observations were substantially the same as those noted during the August 2007 VA examination, which was undertaken in connection with his original claim for service connection and is outside the one-year look back period from the date of the September 2008 claim. During the October 2008 VA examination, the Veteran reported that he found his concentration was not as good as it used to be, that he did not trust his thinking, and that he did not like feeling dependent. In this regard, he reported having his wife take over financial responsibilities that he used to have. He also reported experiencing nightmares at times as often as two to three times per week, but then going several months without any nightmares. On objective examination, the October 2008 VA examiner noted the Veteran was neatly dressed, well-groomed, fully oriented, and that there was no objective evidence of impairment with thought processes or communication. The Veteran denied having delusions or hallucinations and reported that he was able to take care of his activities of daily living without help. The examiner noted that the Veteran’s memory was adequate but that he had some problems with concentration. The examiner also noted that the Veteran was able to take care of his finances. VA and private treatment records are consistent with the findings in the October 2008 VA examination report. The Board finds that the aforementioned psychiatric symptoms are of the duration, frequency, and type that more nearly approximate the 30 percent disability rating criteria. In this regard, his feelings of not trusting others are akin to “suspiciousness” listed in the 30 percent disability rating criteria. The Board finds that the Veteran’s difficulty concentrating is of the type, frequency, and duration of the 30 percent criteria as it appears to be mild. The examiner found the Veteran’s memory to be adequate but acknowledged that the Veteran had some difficulty with concentration. There is no indication of any flattened affect, abnormal speech, difficulty understanding complex commands, more than mild impairment of short and long-term memory, impaired judgment, impaired thinking, disturbances of motivation and mood greater than “depressed mood”, or difficulty in establishing and maintaining effective work and social relationships. The Veteran has not reported experiencing any panic attacks during this period. However, even if the Board views the Veteran’s nightmares as akin to “panic attacks,” they did not occur with the frequency, duration, or type as contemplated by the 50 percent disability rating criteria. The Veteran reported that he experienced the nightmares one to two times per week at times but that then he would go months without a nightmare. Thus, the Board finds the Veteran’s nightmares more nearly approximate the weekly or less often panic attacks contemplated in the 30 percent disability rating criteria. For the period from September 9, 2010, the Veteran was afforded a VA examination in September 2010. At that time, he reported that his mood was complacent, that he experienced nightmares one to two times per week, and reported that he did not enjoy his life but felt his was existing. He reported that he perceived his current way of life as best strategy for coping and described efforts to become non-confrontational. He reported that his moodiness had decreased over past few years. He reported that he no longer fought change. He also reported the he had received two to three tickets for speeding and road rage. He specifically reported an incident that resulted in a verbal argument between himself and another driver, 1-2 years prior. He denied getting into any physical altercation even though the other driver reported that the Veteran went after him with a tire iron. Regarding relationships, the Veteran reported that he had been married to his third (current) wife for more than 20 years. He also reported strained relationships with his children. On objective examination, the September 2010 VA examiner noted that while the Veteran reported some improvement in mood disturbance, it appeared that the improvement may have been due in part to avoidance of potential triggers for distress. The examiner noted that the Veteran continued to report anhedonia and irritability that would likely impact ability to function either in sedentary or physical employment setting. The September 2010 VA examiner also administered a Beck Depression Inventory test which resulted in a “severe” rating and noted mild symptoms including suicidal thoughts. The examiner opined that there was no total occupational and social impairment due to PTSD signs or symptoms but that there was impairment in areas including judgment, thinking, family relations, mood. The examiner explained that impairment in judgment was demonstrated by the Veteran becoming involved in physical or verbal altercations with others in a variety of settings. Impairment in thinking was demonstrated by intrusive thoughts of combat experiences as well as difficulty concentrating with short-term memory problems that would likely impact ability to function at work. Impairment in family relations was demonstrated by marked conflict and estrangement from his children as well as feelings of emotional numbness and estrangement from others. Impairment in mood was demonstrated by anhedonia and irritability that would likely impact ability to function at work. The Veteran was provided another VA examination in January 2013. At that time, the Veteran reported experiencing nightmares two times per week. He denied suicidal ideation and hallucinations. The examiner noted that the Veteran had a restricted affect, sense of foreshortened future, and depressive symptoms. The examiner also noted that the Veteran’s thought processes were logical, and speech was appropriate. The examiner determined that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran was provided with another VA examination in September 2017. At that time, the Veteran reported that his wife had noticed that he had become more irritable and angry. He reported that he had been in fights since his last evaluation but that he had not been arrested. He did not describe the altercations but he reported sometimes having shouting matches with his neighbors about their dogs. On objective evaluation, the September 2017 VA examiner noted that the Veteran was casually dressed and had good grooming and hygiene. The examiner noted that the Veteran was calm and cooperative. The examiner noted that the Veteran did not have any unusual behaviors. The examiner noted that the Veteran’s speech was within normal limits and his mood was primarily euthymic with congruent affect. The examiner noted that the Veteran’s thought process was goal-directed and logical. No suicidal ideation or homicidal ideation was endorsed. No hallucinations or delusions were noted. The examiner found the Veteran to be fully oriented in all spheres. The examiner found the Veteran’s memory, concentration, insight, and judgment to all be fair. The examiner concluded that given the testing results and the Veteran’s presentation on interview, his symptoms appeared to be no more nor less severe than they were in 2013. The examiner determined that the Veteran’s symptoms caused occupational and social impairment with reduced reliability and productivity due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control when it comes to irritability and anger. VA treatment records are consistent with the VA examination reports. Based on the foregoing, the Board finds that the Veteran’s symptoms since September 9, 2010 more nearly approximate a 70 percent disability rating. In this regard, the Board places a high probative value on the September 2010 VA examination report which indicated that the Veteran had occupational and social impairment in most areas, including judgment, thinking, family relations, and mood, as well as a severe score on the Beck Depression Inventory. Although the Board acknowledges that the Veteran had many symptoms that only met the 50 percent rating criteria, the Board notes that the September 2010 VA examiner described examples of impairment with judgment, thinking, family relations, and mood that were at the frequency, duration, or type addressed in the 70 percent rating criteria. In reaching these conclusions, the Board has considered the Veteran’s statements and acknowledges his belief that his disability is more severe than the currently-assigned ratings suggest. Indeed, the Board has considered these statements in granting the increased rating for the period from September 9, 2010. However, a 100 percent disability rating is not warranted for the period from September 9, 2010 as there is no indication of 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, at any time. In this regard, although he has had some impairment in thinking, VA examiners have found that he is able to maintain his finances even if he prefers for his wife to do the same due to his forgetting to pay bills. Additionally, he has consistently denied any delusions or hallucinations. Grossly inappropriate behavior has not been shown. Even though he has experienced conflicts with neighbors and others, he has not been arrested or other indication of grossly inappropriate behavior. Despite one report of suicidal thoughts in September 2010, he has not been shown to be in persistent danger of hurting himself or others. He has consistently denied any suicidal attempts. Similarly, even though he has gotten into altercations, they do not appear to be of the frequency, type, or duration as contemplated by the 100 percent rating criteria. He has not been arrested or institutionalized for the same. Treatment records and examination reports do not indicate any disorientation or memory loss for names of close relatives, own name, occupation, at any time. For the foregoing reasons, the Board finds that the Veteran’s PTSD more nearly approximates the currently-assigned rating of 30 percent prior to September 9, 2010, and resolving doubt, 70 percent, but no higher, thereafter. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU Entitlement to a TDIU prior to May 24, 2010 Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. If there is only one service-connected disability, this disability should be rated at 60 percent or more; if there are two or more disabilities, at least one should be rated at 40 percent or more with sufficient additional service-connected disability to bring the combination to 70 percent or more. 38 C.F.R. § 4.16 (a). The United States Court of Appeals for Veterans Claims (Court) has held that the Board has jurisdiction over the issue of entitlement to a TDIU if raised by the evidence of record as part of a claim for a higher initial rating, as is the case here. Rice, 22 Vet. App. at 453. The Board has therefore adjudicated the issue of entitlement to a TDIU based on the evidence before it. Individual unemployability must be determined without regard to any non-service-connected disabilities or a veteran’s advancing age. 38 C.F.R. §§ 3.341 (a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a veteran 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, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. Id. at 361. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a veteran’s favor. 38 C.F.R. § 4.3 In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In Faust v. West, 13 Vet. App. 342 (2000), the Court defined “substantially gainful employment” as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran’s earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to a TDIU is whether a veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). In this case, the Board previously determined that the Veteran’s TDIU claim is part and parcel of the claim for an increased rating for PTSD filed in September 2008. See January 2012 Board decision. As such, the Board views the date of the increased rating claim as the date of the claim for TDIU. Here, the Veteran has had a combined schedular disability rating of 70 percent since December 29, 2003, with ratings stemming from the singular disability that amount to more than 40 percent from March 2005. In this regard, since March 2005, the Veteran has had ratings for diabetes (20 percent) with peripheral neuropathy in all four extremities (10 percent each). Applying the combined ratings table to the ratings that derive from the same disability, diabetes, the Board finds that the criteria for a single disability rated at least 40 percent disabling, are met. Thus, the Board finds that the schedular criteria for TDIU are met for more than one year prior to the date of the September 2008 increased rating claim. As the schedular rating criteria are met for the entire period on appeal, the appeal turns on whether the Veteran is unemployable due to service-connected disabilities. The Veteran is currently service-connected for the following disabilities: coronary artery disease (CAD), prostate cancer, PTSD, diabetes mellitus, type II, low back pain, peripheral neuropathy of all upper and lower extremities, left knee disability, hypertension, and right and left long trigger finger disability. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the service-connected disabilities prevent the Veteran from obtaining or maintaining substantially gainful employment from January 20, 2010. In reaching this conclusion, the Board places a high probative value on a January 2018 VA retrospective opinion regarding the period prior to May 24, 2010. The VA clinician explained that neuropathic pain, such as the Veteran’s, impacts everything a person does because there is often numbness in fingers and toes in between zapping pain. The examiner also noted that when a person has as many risk factors as the Veteran does, related to mental health, the person’s work suffers. The examiner noted that the Veteran would be less likely to be on time to work if his sleep was disrupted from either nightmares or pain, would be more likely to be irritable and unyielding to coworkers who confront him, and would have a great deal of difficulty with motivation related to low mood. Based on the foregoing, the examiner opined that it was likely that the Veteran had a great deal of difficulty both with his ability to secure and retain gainful employment prior to May 24, 2010. The September 2010 rating decision indicates that the AOJ granted TDIU effective May 24, 2010 due to the Veteran’s heart disease symptoms because his heart disease resulted in less energy, less ability to walk, shortness of breath, and rendered the Veteran unable to obtain and maintain physical or sedentary employment. The Board will not disturb this favorable finding, as it appears this award served as the basis for the Veteran’s current SMC award at the housebound rate (with the TDIU rating attributed to the heart disease only (then rated at 60 percent), and remaining disabilities rated at 60 percent or more in combination). That stated, the Board’s award of TDIU at a date prior to May 24, 2010 is based on a finding that such is warranted due to the combined effects of his service-connected disabilities, and cannot be found to be based exclusively on the effects of one disability. Private treatment reports dated in March 2007, April 2008, and May 2009 noted that the Veteran’s CAD was asymptomatic. After filing his claim for increased rating for heart disease, at a March 2010 VA examination, the Veteran reported that he had dyspnea on exertion following walking one-half to one-quarter mile and that he complained of fatigue and lassitude. He also reported experiencing dull tightness in his chest once per week, that lasted for an hour at a time. He also reported occasional postural dizziness. The Veteran’s peripheral neuropathy has been shown to result in numbness and zapping pain. See January 2018 VA opinion. The Veteran’s service-connected low back pain limited his ability to bend. See August 2010 VA joints examination. The Veteran’s service-connected left knee disability is manifested by pain reported at the worst level, use of a cane and brace, and walking limited to 15 minutes or fewer than 50 feet. The Veteran reported having flare-ups nearly every day with sleeping, walking, and movement. See August 2010 VA joints examination. The Veteran’s trigger finger disabilities limit the Veteran’s grip strength due to pain. His wife reported that the Veteran needed assistance with opening bottles, buttoning shirts, and shaving, due to his trigger finger disabilities. See October 2011 statement. The January 2018 VA examiner attributed the Veteran’s great difficulty obtaining and maintaining employment, to the combination of his disabilities. The examiner indicated that the Veteran had the same difficulty obtaining and maintaining employment prior to May 24, 2010 as he did thereafter. The Veteran’s May 2010 employment information form indicates that he worked as an operations manager with a package shipping company. The form also indicates that he worked in a position involving physical strain but had to move to a different position when he was unable to complete the requirements for a physical examination. The November 2011 VA diabetes examination report clarified that the Veteran previously worked in a job with the department of transportation (DOT) and that when insulin therapy was initiated for his service-connected diabetes in 2003, he became disqualified to work for DOT. He reported that then he was given a different job that required prolonged walking and standing which increased bilateral lower extremity pain and swelling. The Board resolves doubt and finds that the Veteran was unemployable prior to May 24, 2010 as he was limited in his ability to perform jobs for which he was trained in DOT, or jobs that required prolonged walking, prolonged standing, bending, or gripping. In this regard, he was limited in his ability to perform jobs involving physical requirements. The Board also finds he was similarly not able to perform non-physical jobs as he was in significant pain due to service-connected disabilities, was irritable, depressed, and unmotivated, and occasionally not well-rested due to nightmares, due to his service-connected PTSD, and had less energy, less ability to walk, shortness of breath, due to CAD. Resolving doubt in the Veteran’s favor, the Board finds that the combination of the Veteran’s service connected disabilities rendered him unable to work prior to May 24, 2010. When the AOJ initially granted TDIU in September 2010 it assigned January 20, 2010 as the effective date. Later, the AOJ determined that because the Veteran filed the formal claim for TDIU in May 2010, the effective date could not be prior to the May 2010 date of claim. However, as discussed above, the Board has determined that the Veteran’s claim for TDIU was part and parcel of the claim for an increased rating filed in September 2008. Thus, the entire period from September 2007 (one year prior to the date of the claim for increased rating) should be considered. The Board finds that the appropriate date for TDIU is January 20, 2010. This is because January 20, 2010 is the date that the Veteran informed VA that his CAD had worsened significantly and VA examination has confirmed that it did in fact worsen significantly. Prior to January 2010, the Veteran’s CAD was asymptomatic. Additionally, although the Veteran’s physical disabilities and diabetes may have prevented employment with DOT or in a field that required strenuous, physical work prior to January 20, 2010, the evidence does not indicate that the Veteran was precluded from working in a management capacity. The Board acknowledges that the January 2018 VA examiner indicated that the Veteran’s PTSD would have resulted in tardiness and tiredness during the work day due to sleep impairment from nightmares; however, the Veteran’s nightmares were not shown to be frequent during the period prior to May 2010. While he may have had some days where he may have been not well-rested due to nightmares, the Board finds that they did not occur on such a regular basis as to result in fatigue and tardiness every day. Further, January 20, 2010 is the earliest date that the Veteran reported CAD symptoms resulting in the extent frequent fatigue, lack of energy, loss of motivation, and shortness of breath exhibited in the March 2010 VA examination. For these reasons, and resolving doubt in the Veteran’s favor, the Board finds that a TDIU is warranted from January 20, 2010 but no earlier. 38 C.F.R. §§ 3.340, 3.341, 4.15, and 4.16. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Donna D. Ebaugh, Counsel