Citation Nr: 18157295 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 16-27 034 DATE: December 12, 2018 ORDER For the entire period on appeal, an increased disability rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. A total disability rating based upon individual employability (TDIU) on a schedular basis due to the Veteran’s service-connected disabilities is granted. FINDINGS OF FACT 1. Throughout the entire period on appeal, the Veteran’s service-connected PTSD does not more nearly approximates total occupational and social impairment. 2. Throughout the entire period on appeal, the Veteran’s service-connected disabilities have rendered him unable to secure or to follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. Throughout the entire period of appeal, the criteria for an evaluation in excess of 70 percent, for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to a TDIU on a schedular basis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from September 1970 to April 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from two rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO): (1) a September 2013 rating decision which granted service connection for PTSD and awarded a disability rating of 70 percent from August 22, 2012; and (2) a March 2015 rating decision which denied a TDIU. The Veteran’s Form 9 did not request a Board hearing. Regarding the applicability of Special Monthly Compensation (SMC), the Veteran does not have a single disability rated at 100 percent with an additional disability rated at 60 percent or more, even when considering TDIU and temporary total ratings. See 38 U.S.C. § 1114(s); see also Bradley v. Peake, 22 Vet. App. 280, 289-90 (2008). In addition, the record does not contain lay or medical evidence indicating that the Veteran is in fact housebound, requires aid and attendance, or that his disabilities result in loss of use of a limb, blindness or deafness. See 38 U.S.C. § 1114(s), (l), (k); 38 C.F.R. § 3.350(a), (b), (i). Accordingly, the Board will not infer the issue of entitlement to SMC. 1. Entitlement to an increased disability rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. 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. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. See 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence of record indicates fluctuations in the severity of symptoms during the course of the rating period on appeal, an assignment of staged ratings is permissible. See Fenderson v. West, 12 Vet. App. 119, 126-28 (1999). The Veteran’s PTSD is currently evaluated as 70 percent disabling under the criteria of Diagnostic Code (“DC”) 9411. See 38 C.F.R. § 4.130. The Rating Schedule for mental disorders, including PTSD, provides as follows: A 70 percent evaluation 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; intermittently illogical obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. See id. A 100 percent evaluation is warranted where 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; and memory loss for names of close relatives, own occupation, or own name. See id. The VA Secretary recently amended the portion of the Schedule for Rating Disabilities dealing with psychiatric disorders and the associated regulations to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replaced them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The DSM-V eliminated the DSM-IV’s reliance upon GAF scores, and accordingly, the Board will no longer afford GAF scores any probative value. See Golden v. Shulkin, 29 Vet. App. 221, 224-25 (2018). Evaluation under § 4.130 is symptom-driven; therefore, symptomatology should be the primary focus when assigning a rating to a given mental health disability, and the frequency, severity, and duration of a veteran’s symptoms must play an important role in determining the appropriate disability rating. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). Significantly, the list of symptoms under the rating criteria is meant to be illustrative, not exhaustive; thus, the Board need not find all or even some of the listed symptoms in order to award a specific disability rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). In fact, it is the level of the veteran’s occupational and social impairment that determines the appropriate disability rating under Section 4.130; accordingly, if the evidence of record demonstrates that the veteran suffers from symptoms listed in the rating criteria or symptoms of a similar severity, frequency, and duration that cause occupational or social impairment equivalent to the criteria for a particular rating, then the corresponding rating shall be assigned. See id. at 443; see also Vazquez-Claudio, 713 F.3d at 117. In addition to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission must also be considered, and the evaluation must rest upon all the evidence relating to occupational and social impairment, not solely the examiner’s assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability for a mental disorder, the extent of social impairment must be considered, but the evaluation shall not be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126(b). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. A claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990), and in order to deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). As an initial matter, the Board notes that in July 2012, a private psychiatrist (Dr. H) diagnosed the Veteran’s depression separately rather than as a symptom of his service-connected PTSD. Where it is not possible to separate the effects of a service-connected disability from a nonservice-connected condition, 38 C.F.R. §§ 3.102 and 4.3 require that reasonable doubt be resolved in the Veteran’s favor and that such signs and symptoms be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Moreover, the Veteran’s treatment records indicate that subsequent providers treated the Veteran’s depression as a symptom of his PTSD. Accordingly, resolving all reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s depression is properly attributed to his service-connected PTSD. The Veteran contends that he began to experience symptoms of PTSD shortly after he was nearly shot by another active service member accidentally discharging his service weapon in close proximity to the Veteran. Throughout the entire period on appeal, the Veteran has reported to various private and VA medical providers that he suffers from anxiety, depression, panic attacks, nightmares, night sweats, flashbacks, anger, hypervigilance, irritability, sleep impairment, memory impairment, social isolation, concentration difficulties, and difficulty adapting to an employment environment. The Board finds that the Veteran is competent to describe the observable symptoms of his service-connected PTSD, and that his statements have been consistent with each other and with the evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996) (citations omitted). Accordingly, because the Board finds the Veteran’s lay statements to be competent and credible, they are therefore entitled to probative weight. See Jandreau, 492 F.3d at 1376-77. In 2012, the Veteran was examined by his private psychiatrist (Dr. H), and he also underwent VA examinations in August 2013 and in January 2015. In July 2012, Dr. H submitted a report of his examination of the Veteran, in which he diagnosed the Veteran with PTSD and chronic major depression. Dr. H indicated that the Veteran reported suffering from the following symptoms: depression 90 percent of the time; crying spells 25 percent of the time; nightmares more than once per week; flashbacks with reminders; intrusive thoughts; occasional panic attacks; sleep disruption; night sweats; low energy; ease of startle; hypervigilance; self-isolation; severe memory impairment; anger; sadness; fear; irritability; concentrating difficulties; difficulty making decisions; difficulty learning new information; difficulty processing emotions in context; and feelings of helplessness and hopelessness. Dr. H prescribed Trazodone, Zoloft, and cognitive behavioral therapy to treat the Veteran’s symptoms and opined that such symptoms indicate dysfunction of the prefrontal cortex. Dr. H also concluded that the Veteran’s service-connected PTSD results in a severely compromised ability to sustain social relationships and total inability to sustain occupational relationships. As a result of these findings, Dr. H opined that the Veteran is permanently and totally disabled and unemployable. In August 2013, a VA examiner diagnosed the Veteran with PTSD and noted that the Veteran reported briefly experiencing some PTSD symptoms in the 1970’s, which initially resolved but subsequently resurfaced in approximately 2010 when the Veteran began to experience major medical issues. The Veteran reported that since his PTSD symptoms have resurfaced, he has become more self-isolative, hypervigilant, irritable, and reluctant to participate in social or family activities. The VA examiner noted also noted that, during the last year of the Veteran’s employment (2010-2011), he had become increasingly self-isolative, anxious, and irritable, and he had been experiencing concentration and attention impairment. The VA examiner also noted that, approximately one year prior to the August 2013 VA examination, the Veteran had begun receiving private mental health treatment and medication, albeit with minimal benefit. The August 2013 VA examiner also indicated that the Veteran reported the following PTSD symptoms: moderate to severe anxiety approximately half of the time; occasional depression; chronic moderate sleep impairment; anger; irritability; suspiciousness; occasional crying spells; panic attacks of moderate intensity about twice per week; nightmares and flashbacks a few times per week; social anxiety; mild attention and concentration difficulties; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including employment or an employment-like setting. The Veteran also reported stress in his marital relationship caused by his self-isolation and irritability, as well as unemployment due to a combination of physical and mental health factors. The August 2013 VA examiner concluded that the Veteran suffered from mild to moderate psychosocial maladjustment, resulting in mild occupational reliability and productivity. The examiner further concluded that the Veteran suffered from occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although he was generally capable of functioning satisfactorily and exhibiting normal routine behavior, self-care, and conversation. In January 2015, another VA examiner confirmed the Veteran’s PTSD diagnosis and opined that the Veteran suffers from occupational and social impairment with reduced reliability and productivity. The January 2015 VA examiner noted that the Veteran continued his prescriptions of Cymbalta and Trazodone, and that the Veteran reported the following symptoms: depression with feelings of hopelessness for five or six days in the past month; anxiety; mild panic attacks with perspiration and irritability; unwanted memories of his PTSD stressor; sleep disruption; periodic nightmares; mild memory loss, such as forgetting names, directions or recent events; social isolation; decreased interest in activities; feeling distant from other people; strong negative thoughts; self-blame; irritability; anger; difficulty experiencing positive emotions; hypervigilance; ease of startle; concentration difficulties; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The Veteran denied any legal, behavioral, or substance abuse history, and he denied any current suicidal or homicidal thoughts, intentions or plans. The January 2015 VA examiner observed that the Veteran arrived on time to his appointment, ambulated using a large cane, and was oriented to time, place and situation. His affect was dysphoric, and he was mildly tearful throughout the examination, but no significant disturbances of thought, communication, or affect were observed. The examiner noted that that the Veteran reported living with his wife, with no one else in the home, that he sees his three adult sons on a regular basis, and that he sees a close college friend once per month. The Veteran did not report any other social relationships or social support. The VA examiner also noted that the Veteran is competent to manage his financial affairs. The Veteran further reported that he had last worked full time in July 2011. The Veteran estimated that, during the last year of his employment, his PTSD symptoms caused him to be absent from work on an average of one to two days per month, although he conceded it was difficult to differentiate between his physical and his mental health challenges because both sets of symptoms frequently occurred simultaneously. The VA examiner also noted that the Veteran had missed six months of work in the year prior to his 2011 retirement. The VA examiner further noted that the Veteran reported several symptoms of PTSD that would likely impact his ability to function in an employment capacity. First, the Veteran’s reported irritability would likely impact his ability to interact with others in an occupation requiring social interaction. Second, his reported ease of startle would likely impact his ability to function in any occupational environment that is loud, unpredictable or changing in some manner. Third, his reported difficulties with sleep would likely impact his ability to function in an occupational environment requiring promptness or alertness. Finally, his reported difficulties with concentration and memory would likely impact his ability to function in an occupational environment requiring adaptive learning or rapid task completion. The Board has carefully reviewed the Veteran’s extensive treatment records and finds that such records from July 2012 generally reflect the symptoms reported in each of the Veteran’s three examinations, with three noted exceptions. First, although the Veteran’s Social Security records indicate that he reported a single episode of suicidal ideation in 2011, subsequently, the Veteran has consistently, and most recently in July 2018, adamantly, denied any suicidal or homicidal ideations. Accordingly, because the record contains no other evidence of the Veteran reporting any suicidal ideations or tendencies, and the evidence does not show that at any time during the entire period on appeal the Veteran has posed a persistent threat to himself or others, the Board finds that this singular incident of suicidal ideation occurring more than six years ago fails to rise to the level of the persistent danger of harm to self or others contemplated by Section 4.130 for a total disability rating. Similarly, although Dr. H noted in a May 2015 treatment record that the Veteran reported occasional hallucinations, the Veteran has otherwise denied suffering from auditory or visual hallucinations at any other point during the appellate period. Accordingly, the Board finds this singular hallucinatory incident to fall well short of the persistence required of delusions or hallucinations by Section 4.130 for a total disability rating. Finally, the Board also takes note of the evidence of record reflecting the Veteran’s treatment at the VA in July 2018, in connection with what the Veteran contemporaneously described as depression which had been worsening over the prior few weeks. The Veteran reported that due to his chronic pain and poor health, his mood had continued to decline, and he had been experiencing irritability, anger, frustration. The July 2018 VA treatment records indicate that the Veteran again denied experiencing any hallucinations or delusions, and that he “adamantly” denied suffering from any suicidal or homicidal ideations. The July 2018 VA treatment records further indicate that the Veteran presented as alert and oriented as to time, place, person, and situation, that his mood was congruent, that his speech was normal in pitch, rate, volume, and prosody, that his thought processes were generally clear and logical, and that his insight and judgment were adequate. No overt evidence of psychotic or manic symptoms were observed. In addition, the July 2018 treatment records are silent for any evidence of gross impairment of thought, grossly inappropriate behavior, intermittent ability to perform activities of daily living, disorientation to time and place, or memory loss of close relatives, his own occupation, or his own name. The records further indicate that the Veteran did not report any of the following symptoms: feelings of hopelessness or helplessness; a history of suicide attempt; thoughts about taking his life; an intent to harm himself; or a current or specific plan to harm himself. The records further indicate that the Veteran had not demonstrated any signs or symptoms of suicidal ideations or behaviors that would suggest the need for intervention or further evaluation. It was further noted that the Veteran possessed the full capacity to make informed medical decisions, was regarded as a reliable source of information, and that, from a psychiatric standpoint, appeared stable and suitable for outpatient treatment. Accordingly, in light of the foregoing lay and medical evidence, the Board finds that at no time during the pendency of this claim have the criteria for a 100 percent disability rating for PTSD been satisfied or approximated. See id. The Veteran’s examination and treatment records consistently reflect the absence of any reports or observations of persistent homicidal or suicidal ideations, persistent hallucinations or delusions, or disorientation to time or place. Nor does the record contain any evidence that the Veteran has exhibited gross impairment in thought processes or communication or grossly inappropriate behavior. In addition, the Veteran has consistently been found to be appropriately groomed and behaved and to possess the ability to perform activities of daily living, including maintenance of minimal personal hygiene. Further, no lay or medical evidence suggests that the Veteran has a memory impairment of such severity that he cannot remember highly learned material such as his own name or the names of close relatives. While the January 2015 examiner noted that the Veteran’s impaired memory caused him to forget to take his medications and to misplace his keys, such memory lapses do not rise to the level of failing to remember the sort of highly learned information contemplated by the criteria for the 100 percent disability rating. Moreover, the evidence of record reflects that the Veteran’s social relationships do not suffer from total impairment. The Veteran reported to the January 2015 VA examiner that he has maintained social relationships with his spouse and with each of his three sons, whom he sees on a regular basis, as well as with a college friend he describes as close. Although the record indicates that the Veteran experienced periods of marital stress and tension as a result of his self-isolation and irritability, the Veteran reported to the January 2015 VA examiner that he has sustained a 43-year marriage to his wife, whom he described as “very loving.” In addition, Dr. H opined in his July 2012 report that while the Veteran’s service-connected PTSD severely compromised his ability to sustain social relationships, it did not render his social relationships totally impaired. Similarly, while both the August 2013 and the January 2015 VA examination reports indicated that the Veteran exhibited difficulty in establishing and maintaining effective social relationships, neither indicated that his PTSD symptoms rose to the level of total social impairment. Accordingly, the Board finds that the evidence of record falls short of establishing total social impairment as contemplated by Section 4.130 for a total disability rating. See Vazquez-Claudio, 713 F.3d at 117-118. The Veteran contends that he has been unable to maintain employment since retiring from his longtime employer in July 2011, and the Board acknowledges that the evidence is at least in equipoise as to whether the Veteran’s service-connected PTSD has resulted in total occupational impairment. While Dr. H’s July 2012 Report concluded that the Veteran’s PTSD symptoms rendered him permanently and totally disabled and unemployable, subsequent VA examination reports in 2013 and 2015 indicate that the Veteran’s occupational impairment does not rise to the level of total or complete. However, even if PTSD-related total occupational impairment were established in this case, the Board finds that, based upon the foregoing evidence of record, the severity of the Veteran’s PTSD symptomatology does not more nearly approximate the level of disability contemplated by a 100 percent rating, because the evidence does not support a finding of total social impairment. As set forth above, a total disability rating under Section 4.130 requires an ultimate factual conclusion that the level of the Veteran’s PTSD symptomatology results in both total occupational and total social impairment, see Vazquez-Claudio, 713 F.3d at 118, and the evidence of record in this case indicates that although the Veteran’s marital relationship suffers from tension and stress caused by his PTSD symptomatology, the totality of the evidence of record does not support a finding that the Veteran’s marital relationship is totally impaired or that his relationships with his adult children and his close college friend are totally impaired as contemplated by a total disability rating. See 38 C.F.R. § 4.130, DC 9411. Accordingly, the Board finds that the Veteran’s PTSD symptomatology more nearly approximates the rating criteria contemplated by the 70 percent disability rating rather than the 100 percent rating, and a rating of 100 percent is not warranted at any point during the period on appeal. Instead, a continued rating of 70 percent, and no higher, during the entire period on appeal is warranted in this case, due to the frequency, severity, and duration of the Veteran’s symptomatology resulting in social and occupational impairment in most areas, particularly in family relations, work and mood. See id. All potentially applicable diagnostic codes have been considered, and there is no basis to assign an evaluation in excess of the rating assigned herein for the Veteran’s disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In addition, the Board is not required to address additional issues unless specifically raised by the Veteran or reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017). In this case, because neither the Veteran nor his representative has raised any other issue concerning the Veteran’s PTSD, and no other issues have been reasonably raised by the record, the Board finds that a disability rating of 70 percent for the Veteran’s service-connected PTSD throughout the entire period on appeal is warranted. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 2. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is granted. The Veteran contends that his service-connected disabilities have precluded him from obtaining and maintaining substantially gainful employment for the entire period on appeal. Where a veteran’s schedular rating has been evaluated at less than 100 percent, total disability ratings for compensation may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or to follow a substantially gainful occupation as a result of one or more service-connected disabilities and without regard to advancing age or any nonservice-connected disabilities. See 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a). Under 38 C.F.R. § 4.16(a), a determination concerning unemployability must be made on the basis of service-connected disabilities alone; nonservice-connected disabilities must be disregarded. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Even if the record contains evidence that a veteran’s unemployability is a result of other nonservice-connected factors such as age or nonservice-connected conditions, a finding must still be made, without regard to the nonservice-connected conditions, as to whether the veteran’s service-connected disabilities are sufficiently incapacitating as to render him unemployable. See id. The veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be considered. See 38 C.F.R. § 4.16(b). Total disability will be considered to exist when there is any impairment of mind or body which is sufficient to render it impossible for the average person to secure or to follow a substantially gainful occupation. See 38 C.F.R. § 4.15. While the rating is based primarily upon the average impairment of earning capacity, 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 effect of combinations of disability. See id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. See 38 C.F.R. § 4.16(a); see also Moore v. Derwinski, 1 Vet. App. 356, 358-59 (1991). The ability to work only a few hours a day or only sporadically does not qualify as an ability to engage in substantially gainful employment. See id. Marginal employment shall generally be deemed to exist when a veteran’s earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. See 38 C.F.R. § 4.16(a). Marginal employment may also be established, on a facts found basis, when earned annual income exceeds the poverty threshold, including but not limited to employment in a protected environment such as a family business or sheltered workshop. See id. Consideration must be given in all claims to the nature of the employment and the reason for termination. See id. Certain percentage requirements must be satisfied in order to qualify for schedular consideration of entitlement to TDIU. Specifically, if unemployability is the result of only one service-connected disability, this disability must be ratable at 60 percent or more. See 38 C.F.R. § 4.16(a). If it is the result of two or more service-connected disabilities, at least one must be ratable at 40 percent or more, with the other disabilities sufficient to bring the combined rating to 70 percent or more. See id. The existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the veteran unemployable. See id. In this case, the Veteran has been awarded a 70 percent disability rating for his PTSD, effective August 22, 2012, a 30 percent disability rating for his headache disability, effective November 21, 2017, and a 10 percent disability rating for his low back disability, effective November 21, 2017. Accordingly, the Veteran meets the schedular rating criteria for a TDIU under § 4.16(a), and the Board must consider whether the Veteran’s service-connected disabilities render him unable to secure and to follow substantially gainful employment. For the reasons set forth below, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s service-connected disabilities render him unable to secure and to follow substantially gainful employment, and a TDIU is therefore warranted in this case. The Veteran contends that his service-connected PTSD has prevented him from engaging in full-time employment since July 15, 2011. This assertion is consistent with Social Security records reflecting the Veteran’s application for disability benefits effective August 2011, and his former employer’s statement that July 15, 2011 was his last date of employment. In his July 2012 Report, Dr. H opined that because the Veteran’s PTSD symptoms rendered him unable to sustain occupational relationships, Dr. H found him to be permanently and totally disabled and unemployable. Specifically, Dr. H’s report indicated that the Veteran’s occupational abilities were impaired by the following PTSD symptoms: depression 90 percent of the time; crying spells 25 percent of the time; severe memory impairment; panic attacks; nightmares; flashbacks; sleep impairment; night sweats; irritability; feelings of hopelessness and helplessness; anger; sadness; fear; hypervigilance; ease of startle; concentration difficulties; and difficulties making decisions, learning new information, and processing emotions in context. Furthermore, the 2015 VA examiner clearly indicated that the PTSD symptoms would impact physical and sedentary employment as he could not operate in an environment with loud, unpredictable or changing nature, in an environment that required promptness or alertness or learning new tasks or rapid task completion. As set forth above, the Board finds Dr. H’s July 2012 opinion and the VA examination to be both competent and credible, and therefore entitled to significant probative weight as to the impact of the Veteran’s service-connected PTSD on his ability to secure and to follow a substantially gainful occupation. See Nieves-Rodriguez, 22 Vet. App. at 303-304; see also 38 C.F.R. § 3.159(a). In light of the evidence reflecting that the Veteran’s unemployment during the period on appeal is the result of the manifestations of his service-connected PTSD, considering the evidence indicating that the Veteran has been unable to obtain or maintain substantially gainful employment throughout the entire period on appeal, and given the medical evidence reflecting that his sustained unemployment is related to his service-connected PTSD, the Board finds that, resolving all reasonable doubt in the Veteran’s favor, a TDIU is warranted for the entire appellate period. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; see also Gilbert, 1 Vet. App. 49, 55. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Hannah Marsdale, Associate Counsel