Citation Nr: 18156638 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 15-21 897 DATE: December 11, 2018 ORDER Entitlement to an initial 70 percent rating for posttraumatic stress disorder (PTSD) is granted, subject to regulations governing payment of monetary benefits. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted, subject to regulations governing payment of monetary benefits. FINDINGS OF FACT 1. The Veteran’s PTSD has caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking or mood, but not total occupational and social impairment 2. . The Veteran meets the schedular criteria for TDIU and his service-connected disabilities prevents him from engaging in substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent rating, but not higher for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.130, Diagnostic Code (Code) 9411. 2. The criteria for an award of TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.40, 3.41, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2011 rating decision which granted service connection and assigned an initial 30 percent rating for PTSD, effective November 9, 2010. In an interim May 2018 rating decision, the rating for PTSD was increased to 50 percent, effective November 6, 2017. The Veteran filed an application for TDIU in May 2012. That claim is before the Board as part of the increased rating claim for the psychiatric disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Increased Rating The Veteran’s service-connected PTSD with major depressive disorder has been evaluated as 30 percent disability from November 9, 2010, and as 50 percent disability from November 6, 2017 under 38 C.F.R. § 4.130 Code 9411. Disability ratings are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate Codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board concludes that an initial 70 percent rating, but no higher, is warranted for the Veteran’s PTSD. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating a mental disorder, consideration shall be given to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The evaluation will be based on all the evidence of record that bears on occupational and social impairment rather than solely on an examiner’s assessment of the level of disability at the moment of examination. It is the responsibility of the rating specialist to interpret reports of examinations in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity. This may be 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assignable for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A rating of 100 percent is assignable for 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. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a Veteran’s symptoms, but it must also make findings as to how those symptoms impact a Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In his November 2010 claim, the Veteran described his mental condition as including anxiety, severe depression, agoraphobia, and PTSD. In a December 2010 VA treatment note, the Veteran reported having recent increased feelings of anxiety, fear and paranoia. He described himself as feeling like a “target” and was isolating himself more and more. He denied any significant nightmares, suicidal ideation, and auditory hallucinations. On depression screening he described having little interest or pleasure in doing things nearly every day; feeling down, depressed or hopeless for several days; feeling bad about himself or that he was a failure or left himself or his family down for several days; and he found it that his problems have made it somewhat difficult to work, take care of things at home or get along with others. He also described that he had no recent thoughts of taking his life, but had hopeless feelings about the present or future. On March 2011 VA examination, PTSD was diagnosed. The Veteran reported having a close relationship with his partner and 3 daughters. He reported he has a reduced social activity with his own friends and relies on his partner’s social contacts. He reported he had no history of suicide attempts or violence. On mental status examination, he appeared casually dressed; his psychomotor activity was normal; speech was unremarkable; he was cooperative to the examiner; affect was full; mood was anxious and depressed; attention was intact; he was oriented to person, time, and place; thought process and content were unremarkable; no delusions; average intelligence; he understood he has a problem; he had no sleep impairment, hallucinations, inappropriate behavior, obsessive behavior, panic attacks, suicidal or homicidal thoughts. He was able to maintain personal hygiene and had no problems with activities of daily living. Remote, recent, and immediate memory were normal. The PTSD symptoms included irritability, outbursts of anger, and hypervigilance. The examiner opined that his symptoms caused clinically significant distress or impairment, in social, occupational or other important areas of functioning. The Veteran was capable of maintaining his financial affairs. He was also employed fulltime as a massage therapist. In April 2011, the Veteran received a service dog to help him deal with his anxiety. Mental status examination detailed in a June 2011 VA treatment record note the Veteran appeared his documented age and casually dressed; mood was anxious; affect was anxious and distressed; psychomotor was within normal limits; speech and language were soft voice and slightly hurried speech; thought processes was circumstantial; thought content included recent episodes of anxiety; assessment of insight was fair to good; and assessment of judgment was good. He had a recent episode of suicidal ideation which lasted a couple of hours and was distressing. The Veteran reported he continued to have suicidal ideation, but it was mostly fleeting. In a May 2012 statement, the Veteran reported an increase in his PTSD symptoms including suicidal ideation; obsessional rituals; intermittent speech; obscure speech; panic; depression; unprovoked; irritability; neglect of personal appearance; hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships. He also reported having spent 3 days in the hospital for a suicidal episode. On June 2012 VA examination, an anxiety disorder with agoraphobia with a history of panic attacks, borderline personality disorder, depression, and PTSD were diagnosed. The examiner indicated it was possible to differentiate the symptoms between the Veteran’s diagnosed psychiatric disorders. The Veteran’s PTSD symptoms included hypervigilance, anxiety, impaired judgment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner noted the Veteran was recently hospitalized for suicidal ideation and he had thoughts of self-injury, but the examiner found those symptoms related to depression and probable personality disorder. The examiner also noted the Veteran was in a supportive and committed relationship and had three daughters from a previous marriage, but he continued to have conflict with extended family. The Veteran reported he works as a massage therapist and feels safe at work, but finds it stressful listening to other people’s problems. The examiner opined that his PTSD symptoms independently caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner also noted the Veteran was capable of managing his finances. In a letter received in June 2012 from the Veteran’s partner, he reported that the Veteran often has anxiety and panic attacks, and thoughts of suicide. He described that the Veteran was barely sleeping because he gets frightened of little noises and wakes up throughout the night jumping in fear. He noted that it was difficult to get the Veteran out of their house because he has problems with crowds, but he had recently had trouble going to places without crowds such as parks or mountains. He also described that the Veteran’s psychiatric disorder has caused him to have no social life or the ability to keep connections with people. He only has a few close friends that visit their apartment regularly to offer him support. In a June 2012 statement, the Veteran reported that his disability causes him difficulties to the extent that thinking of killing himself brings relief. He described his suicidal ideation was getting more frequent and that he feels he is losing his ability to control it. He reported that he is depressed most of the time, but he uses a service dog and medication to help manage his depression. He has difficulties remembering things such as his plans or what happened the day before, as well as names, places, and things. He reported he has trouble sleeping and is easily startled. He described that he has difficulty when he is with more than three unknown people of five known people, and his heart will race and palms with get sweaty. He reported he is distant from his few friends, but has good relationships with his partner, parents, and daughters. In his August 2012 notice of disagreement, the Veteran reported that he struggles to leave his apartment, yells when he hears a loud noise, has problems with public places, and has been battling depression and suicidal ideation for a long time. He indicated he was seeking a 70 percent rating for his PTSD. In a November 2013 VA treatment note, the Veteran reported having panic attacks when he is in a crowded area. He described that when he is in a crowd he becomes highly anxious, finds it hard to breathe, his heart races, and he feels as “everything freezes up.” He reported that these feelings can collapse into feelings of suicidal ideation, worthlessness, and rejection by others. He also reported feeling disconnected and isolated from others. The provider opined that the Veteran is likely highly reactive to negative stimuli, and these fears are manifested in his pattern of suicidal ideation and dramatic swings in his emotional functioning. On April 2014 VA examination, PTSD, unspecified anxiety disorder with symptoms of panic, and personality disorder were diagnosed. The examiner noted it was possible to differentiate the symptoms attributed to each diagnosis. The examiner found the Veteran’s PTSD symptoms included intrusive thoughts and memories, irritability, initial insomnia, problems with concentrating and memory, hypervigilance, exaggerated startled response, emotional numbing, and avoidance of triggering situations. The examiner noted the Veteran had acute symptoms of anxiety when he was in public that results in him pacing and exacerbated irritability. The examiner found the symptom of his personality disorder included emotional lability, suicidal gestures, significant feelings of emptiness and low self-worth, and significant concerns of abandonment. The examiner opined that the Veteran’s psychiatric symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. When addressing at The examiner noted his personality disorder primarily affected his occupational and social impairment and his PTSD and anxiety disorder had a secondary impact. On June 2015 VA examination, the examiner opined that the Veteran’s symptoms of PTSD and major depression could be distinguished from the symptoms of his personality disorder. The examiner found the symptoms associated with his PTSD and major depression included sleep impairment, mild memory loss, as well as “intrusive thoughts and memories, irritability, initial insomnia, problems with concentration and memory, hypervigilance, exaggerated startle response, emotional numbing and avoidance of triggering situations.” The examiner opined that solely his PTSD symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. She also noted that the Veteran’s primary impairment, instability, and lack of mood regulation were due to his personality disorder. In an October 2015 private treatment note, the Veteran was noted to have severe PTSD symptoms including hypervigilance and avoidance, and difficulty leaving his home. The provider noted he was at a moderate risk of self-harm, as he had suicidal ideation but no intentions of carry through with the act. On mental status examination, the Veteran appeared his stated age in casual clothes and with good hygiene. He appeared markedly anxious, but cooperative with interview. He made fair eye contact, was mildly fidgety, but had no ties, tremors or abnormal movements. His speech had an anxious tone, but volume, rate and rhythm were normal. His thought process was logical and goal-directed, and his thought content was reality based and focused on recent events. There was no evidence of delusions or hallucinations. He had some suicidal ideation with no suicidal intent or plan at this time. He had no homicidal ideation. His mood was anxious, affect was congruent, and cognition was grossly intact. Insight and judgment were fairly good. In a November 2017 PTSD disability benefits questionnaire (DBQ) completed by the Veteran’s private provider, based on a review of his private treatment records, the provider noted the Veteran had PTSD, generalized anxiety disorder, panic disorder, and agoraphobia diagnosed. The provider noted that he could not differentiate which symptoms were attributable to each diagnosis because his hypervigilance associated with PTSD overlaps with generalized anxiety as with his panic and agoraphobia. The provider noted that the Veteran had multiple suicide attempts and at least 6 psychiatric hospitalizations. The Veteran’s symptoms included feeling of detachment or estrangement from others; difficulty concentrating; hypervigilance; exaggerated startle response; depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work-like setting; suicidal ideation; and the intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The provider opined that his symptoms resulted in occupational and social impairment with reduced reliability and productivity. In a November 2017 PTSD DBQ completed by the Veteran’s VA social worker, chronic PTSD, recurrent major depressive episodes, Asperger’s syndrome, and suicidal ideation were diagnosed. The provider noted it was possible to differentiate which symptoms were attributable to each diagnosis. She noted that his PTSD manifested in symptoms including both internal and external reminders of trauma, and hypervigilance, and his depression resulted in periods of prolonged sadness not explained by other conditions. She also noted that his symptoms of PTSD included nightmares, environmental triggers, avoidance of crowds, struggling with connecting with others, developing relationships, difficulty sleeping, difficulty concentrating, and hyperarousal. The provider opined that the Veteran’s mental symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. She also opined that it was possible to differentiate what portion of the occupational and social impairment caused by each mental disorder. She noted that his depression causes a lack of motivation to engage in worthwhile activities, occupationally and socially, and his PTSD causes avoidance and worry based on behaviors to keep him from goals. On April 2018 VA examination, the examiner noted diagnoses of PTSD, major depressive disorder, unspecified anxiety disorder with panic symptoms, borderline personality disorder. The examiner noted that the Veteran’s anxiety continues to be closely linked to his personality disorder and related concerns about self-esteem and feelings overwhelmed by stress. The examiner noted it was possible to differentiate what symptoms are attributable to each diagnosis. His PTSD symptoms included intrusive thoughts and memories, irritability, initial and middle insomnia, problems with concentration, hypervigilance, exaggerated startle response, emotional numbing and avoidance. His depression symptoms included dysphoric and “sad” mood, feeling helpless and hopeless about the future, low energy, motivation, and productivity. His anxiety disorder symptoms included acute symptoms of anxiety that occurs in public and during periods of high stress. His personality symptoms included emotional lability, suicidal gestures, difficulties managing stress, feelings of emptiness, low self-worth, and fear of abandonment. The Veteran reported that he spends most of his time at home high on marijuana, walking around his couch playing games by himself on his iPad. He does chores around the house including laundry and the dishes and cooks simple meals because he is easily frustrated and does not go to the store. He also reported that his husband often reminds him to take basic actions such as showering or shaving. He also walks in a local park twice a week and to a neighborhood gym, but only when it is not busy. The Veteran reported that his husband and service dog are his primary support system and he only has one friend from childhood. He described that his husband’s friends will come to their house and he will talk with them, but he has a tendency to sneak away to avoid a high level of sensory input. The examiner opined that the Veteran’s mental symptoms resulted in occupational and social impairment with reduced reliability and productivity. He found it was possible to differentiate what portion of the impairment was caused by each mental disorder. He opined the Veteran’s service-connected PTSD and depression had approximately the same impact on his work and social impairment as his nonservice-connected anxiety disorder and personality disorder. The examiner also opined that the Veteran was capable of managing his finances. In an October 2018 VA treatment note, the Veteran reported that he was feeling better but he was still struggling with hypervigilance and exaggerated startled response because there is construction going on at his apartment building. The Veteran’s VA and private treatment records throughout the period on appeal also reflect that the Veteran has had at least passive suicidal ideation throughout the period and he was hospitalized multiple times due to suicidal ideation beginning in May 2012. He reported two suicide attempts and occurrences of self-harm where he would hit his head against a wall. He also experienced audio-hallucinations telling him to kill himself during hospitalizations in June and July 2015. However, as noted above VA examiners attributed such behavior to the Veteran’s personality disorder and not his service-connected PTSD. Based on the review of the record, the Board finds that entitlement to an initial 70 percent rating, but not higher, for PTSD and major depressive disorder is warranted for the entire appeal period. The Board acknowledges that throughout the period on appeal the Veteran has had chronic psychiatric symptoms attributable to multiple mental disorders. VA examiners have been able to separate the symptoms attributable to the Veteran’s service-connected PTSD and major depression disorder from the personality disorder, and separate the impact of those symptoms on his occupational and social impairment. Throughout the entire period on appeal, the Veteran’s psychiatric symptoms have included feelings of emotional difficulties, low self-worth, and thoughts of self-harm and suicide, which resulted in suicide attempts. However, VA examiners in June 2012, April 2014, June 2015, and April 2018 each attributed these symptoms to his nonservice-connected personality disorder. Throughout the entire period on appeal, the symptoms attributable to his PTSD and major depressive disorder included depression, anxiety, agoraphobia, hypervigilance, exaggerated startle response, reduced social activity, impaired judgement, difficulty sleeping, and mild memory loss. The Veteran and his husband both reported that he had difficulty leaving his home, difficulty with groups of known or unknown people, and distant himself from his friends. On April 2018 VA examination, the Veteran also reported that he had to be reminded by his husband to do basic functions such as showering and shaving. Accordingly, throughout the entire period on appeal, the Veteran’s symptoms and functional impairment revealed deficiencies in areas of work, school, family relations, thinking, and mood due to symptoms such as impaired impulse control, difficulty in adapting to stressful circumstances, neglect of personal appearance and hygiene, and the inability to maintain effective relationships. An evaluation higher than 70 percent is not warranted for the Veteran’s PTSD and major depression disorder because the effect of the symptoms do not more closely approximate the disability picture contemplated by a 100 percent rating. 38 C.F.R. § 4.130, Code 9411. The evidence does not reflect that the Veteran’s PTSD and major depression disorder symptoms demonstrate total occupational and social impairment. The evidence does not show that the Veteran exhibited 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 due to his PTSD and major depressive disorder. While the Veteran reported he had to be reminded to do things such as shower and shave, throughout the period on appeal, the Veteran consistently appeared adequately dressed on examination and during treatment and showed no impairment in thought processes or communication. While the Veteran exhibited suicidal ideation throughout the period and reported two suicide attempts, he was not found to be in persistent danger of hurting himself, and such symptoms were attributed to his personality disorder by multiple VA examiners. Additionally, while the Veteran reported having mild memory loss during the period on appeal was it shown he could not remember names of close relatives or his own. TDIU Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341(a). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. The Veteran is service-connected disabilities for PTSD, tinnitus, and melasmas. Given the Board’s decision here to increase the rating for PTSD to 70 percent for the entire period on appeal, the schedular criteria for a TDIU rating are met for the entire appeal period. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The fact that a veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In making its determination, VA considers such factors as the extent of the service-connected disabilities, and employment and educational background. 38 C.F.R. §§ 4.16 (b), 4.19. In his May 2012 application for TDIU, the Veteran reported that his psychiatric disorder had prevented him from securing of following any substantially gainful occupation. He reported he last worked full-time in May 2012 when he became too disabled to work. He indicated that he was self-employed, working 20 hours per week as a massage therapist since 2005, and worked during service in air transportation and as military police in a correctional facility. He also reported he has an Associate Degree. In a statement received in May 2012, the Veteran reported he is only able to work 2 hours a day on a good day. On June 2012 VA examination, the Veteran reported that he continues to do some work as a massage therapist and has continued working even during periods of increased psychiatric symptomatology. During an interview he reported that he feels safe at home and at work, but experiences discomfort in public. He also indicated at that time that he wanted to return to school and pursue a career in solar energy. The examiner found the Veteran’s PTSD symptoms included hypervigilance, anxiety, impaired judgment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. In a June 2012 statement, the Veteran reported that he has difficulty when he is with more than three unknown people of five known people. In a May 2013 VA treatment note, the Veteran’s social worker opined that completing a school program such as vocational rehabilitation may be unrealistic for the Veteran given hs vulnerability to intense anxiety in a classroom setting with more than 10 people. He noted the Veteran was bright and capable in a controlled environment, ideally working on solo tasks. He also noted that the Veteran was drawn to industrial sewing or other hands-on assembly or repair work, and was fairly computer savvy. In an April 2013 Vocational Rehabilitation assessment, the Veteran was determined not to be capable of working full time, but could work 8 hours a day for 3 days a week. The social worker opined that under controlled conditions, the Veteran is quite capable, however he has low tolerance for being in large groups of crowds, and low stress in general. He would likely do well in a skilled repair or assembly work where he is working on his own. He was also unlikely to do well in a large classroom setting. In a July 2013 vocational rehabilitation counseling record, the Veteran was found to have a vocational impairment, an employment handicap, and a service-connected disability that contributed in substantial part to his vocational impairment. The reviewing counselor opined that his vocational goal was not currently reasonably feasible based on the May 2013 VA treatment not that found that the Veteran was emotionally stable only when he was not around groups of people. Therefore, education was ruled out, and he was not feasible for employment until he can stabilize himself and greatly improve his stress tolerance. In January 2014, his vocational rehabilitation program was discontinued because no rehabilitation plan had been developed. An October 2013 Social Security Administration (SSA) decision shows that the Veteran reported that he became unable to work on November 15, 2005 due to his PTSD, depression, and agoraphobia. However, SSA determined that his condition was not severe enough to meet SSA disability requirements until February 1, 2013, and established disability from that date. In a November 2013 VA treatment note, the Veteran reported that he had been unemployed for several years and his anxiety was making it difficult to find a job. He reported doing some work on his computer for his husband’s organization, but it was manageable because it required limited social interaction. He also reported taking online classes in computer programming. In a November 2013 VA treatment note, the Veteran reported that he was currently taking some classes in computer programing, but these were online classes and he failed a course when he was required to attend class on campus. In a December 2013 letter, a VA psychologist determined that it was not feasible for the Veteran to return to employment. In an April 2014 statement, the Veteran reported that after leaving service he worked as a licensed massage therapist and as his conditions worsened, his business declined. He described that he would obsess and worry about who was his next client. He closed his business due to negative income in 2012. On April 2014 VA examination the Veteran reported he had not worked for an income since 2012, when he was a massage therapist for 5 years. He reported that he stopped working in this field due to problems with his shoulders. He also reported that he would experience anxiety before a session. The examiner noted that in terms of current employment, the Veteran reported that he has difficulties working with people, and he stresses over not meeting the expectations people have for him. The Veteran did report that he helps his husband with event organization, such as assisting setting up and taking down chairs, but that he avoids the event when it is full of people. The examiner opined that the Veteran was not able to maintain gainful competitive employment. The examiner noted that his personality disorder and anxiety/panic disorder are the primary factors in his opinion, and based solely on his service-connected mental health conditions, the Veteran would be expected to work in a loosely supervised situation. In an April 2014 statement, the Veteran reported that he put his massage license on hold because he cannot continue school to keep it. He feels unsafe in a room full of people and a class room setting causes panic attacks. A September 2014 decision by the Oregon State Vocational Rehabilitation Division indicated that the Veteran was recently psychiatrically hospitalized, was not ready to enter the workforce, and presumed he was not ready to undergo formalized training. The reviewing psychologist also opined that the Veteran may only be able to tolerate working part-time as he has already had 2 full years of behavioral therapy and has difficulty in regulating his emotions. In a June 2015 vocational rehabilitation counseling record, the Veteran was found to have a vocational impairment, an employment handicap, and a service-connected disability that contributed in substantial part to his vocational impairment. The reviewing counselor opined that his vocational goal was not currently reasonably feasible. The counselor explained that the Veteran became suicidal for three days after failing his on-line Trigonometry class when he could only fill in half the answers and he is able to go out in public with the use of a service dog. While the Veteran had made small improvements over the previous year, he had not been able to gain the capacity to be in public without crippling anxiety. Accordingly, the counselor opined that he will have to make major gains in his ability to cope with anxiety before he can effectively work with people in a competitive environment. The Veteran was notified that his vocational rehabilitation program was interrupted because he was not able to continue his education due to overwhelming anxiety. In a November 2017 DBQ, the Veteran’s VA social worker opined that the Veteran’s symptoms of PTSD has affected his ability to pursue and maintain employment consistently. She indicated that due to his hypervigilance or inability to concentrate, he cannot complete a college course, volunteer consistently, or not know if he will be able to leave the house that day due to anxiety and fear for being in public. On April 2018 VA examination, the Veteran reported that he had not worked for an income since 2010 to 2011 when he was employed as a massage therapist. He reported he stopped working due to problems with his shoulders and after quitting he tried to volunteer, but was easily upset when people were rude to him. He reported that his PTSD and depression keep him from working. He described he becomes anxious, overwhelmed, and highly distressed when he is required to complete tasks within a certain time frame. He also describes he is avoidant of people and does not want to leave his home. The examiner opined that based solely on his PTSD and depression it would be expected that the Veteran could work in a loosely supervised situation that requires minimal interaction with the public. Based on a review of the record, the Board finds that entitlement to TDIU is warranted. The Veteran asserts that he is unemployable due to his psychiatric symptoms. The record shows that the Veteran has been unemployed since May 2012 when he stopped working as a massage therapist, and that he has an Associate Degree. Both the April 2014 and April 2018 VA examiners opined that the Veteran could work in a position with loose supervision, with the April 2018 examiner specifying also in a job with minimal interaction with the public. Nevertheless, the ultimate question of whether a Veteran is capable of securing or following substantially gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). The Board finds that the Veteran’s service-connected PTSD and major depressive disorder has precluded him from being able to maintain substantially gainful employment. The Veteran’s work history involved interacting with other people, and the Veteran’s PTSD and major depressive disorder has manifested in symptoms effects his ability to effectively interact with others as well as his ability to leave his home. Throughout the period on appeal, the Veteran’s service-connected PTSD and major depressive disorder has manifested in symptoms including agoraphobia and fear of crowds, hypervigilance, impaired judgement, difficulty concentrating, and anxiety. In an April 2014 statement, the Veteran reported that even while working he would obsess and worry about his next client and on April 2014 VA examination he described having anxiety before a session. Additionally, during the period on appeal, the Veteran reported that he had helped his husband with organizing events for his organization, but this reflected that he worked in a protected environment as he was protected from interacting with other people and would leave before events would start. He reported on April 2018 VA examination that he tried to volunteer but became easily upset when people were rude to him. On April 2018 VA examination the Veteran also reported that he will have to leave the room when the stimulation from his husband’s friends gets too much when they visit. The Veteran’s VA providers consistently noted he would not do well in a classroom environment due to his PTSD symptoms, and the Veteran reported he failed an on-line course when he had to attend on campus. The record reflects the Veteran had several attempts to participate in vocational rehabilitation, however, each attempt was never completed due to his inability to participate in a classroom environment. Further, the Veteran’s VA social worker opined in the November 2017 DBQ, that due to his hypervigilance or inability to concentrate, the Veteran cannot complete a college course, volunteer consistently, or not know if he will be able to leave the house that day due to anxiety and fear for being in public. The Veteran also reported having difficulties with his memory and ability to concentrate. He described failing a math course when he could not complete the test. On April 2018 the Veteran also reported that becomes anxious, overwhelmed, and highly distressed when he is required to complete tasks within a certain time frame, and that his husband has to sometimes remined him to complete basic tasks of life such as showering and shaving. (Continued on the next page)   Accordingly, and resolving any reasonable doubt in the Veteran’s favor, the Board finds that the Veteran has been precluded from securing and following gainful employment due to his service-connected PTSD and major depressive disorder, and TDIU is warranted. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Eric Struening, Associate Counsel