Citation Nr: 1806726 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 14-07 802 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating due to individual unemployability resulting from service-connected disability (TDIU). ATTORNEY FOR THE BOARD R. Gandhi, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1982 to August 1985 and April 2006 to July 2008. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina FINDINGS OF FACT 1. For the period prior to May 26, 2011, the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. 2. For the period after May 26, 2011, the Veteran's service-connected PTSD more nearly approximates occupational and social impairment with deficiencies in most areas due to psychiatric symptoms; but it has not resulted in total occupational and social impairment. 3. The Veteran is service-connected for PTSD, rated at 50 percent disabling prior to May 26, 2011and at 70 percent after May 27, 2011; sleep apnea, rated at 50 percent disabling; right leg phlebitis, rated at 10 percent disabling; and hypertension, rated at 0 percent disabling. 4. Affording the Veteran the benefit of the doubt, the evidence demonstrates that his service-connected disabilities prevent him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 50 percent, but no higher, for PTSD have been approximated for the period prior to May 26, 2011. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2017). 2. The criteria for an evaluation of 70 percent, but no higher, for PTSD have been approximated for the period after May 26, 2011. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2017). 3. The criteria for entitlement to TDIU on a schedular basis have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. PTSD 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. 38 C.F.R. § 4.7. VA should interpret reports of examination in 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. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. 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). Since the Veteran appealed the initial rating assigned for his PTSD, the entire body of evidence is for equal consideration. Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be staged. Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 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. 38 C.F.R. § 4.126. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where, as here, the question for consideration is a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the Veteran's PTSD is assigned an initial 50 percent disability evaluation from May 2009, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under Diagnostic Code 9411, a 50 percent rating is assigned 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. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the psychiatric disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The use of the term "such as" in the general rating formula for mental disorders 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 symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. The GAF is a scale which reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The Board notes that GAF scale was removed from the more recent DSM-V for several reasons, including its conceptual lack of clarity, and questionable psychometrics in routine practice. See DSM-V, Introduction, The Multiaxial System (2013). Still, the GAF score and interpretations of the score are important considerations in the rating of a psychiatric disability, though the GAF score assigned to a veteran is not dispositive of the severity of the veteran's mental health disability. See Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). The GAF score must be considered in light of the actual symptoms manifested by the veteran's disorder, which must provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). According to the pertinent sections of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV), a GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors, and that the examinee suffers no more than slight impairment in social, occupational, or school functioning. A GAF score of 61 to 70 indicates some mild symptoms, or that the examinee suffers from some difficulty with social, occupational, or school functioning, but that the examinee generally functions well and has some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. A GAF score of 31 to 40 indicates that the examinee has some impairment in reality testing or communication, such as illogical, obscure, or irrelevant speech, or that the examinee has major impairment in social, occupational, or school functioning. See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). A October 2008 VA treatment record notes that the Veteran was given a diagnosis of PTSD with some reservation as it was noted that objective testing suggested that the Veteran was negatively exaggerating his memory complaints. The Veteran endorsed symptoms of depression, loss of some interest in activities, and problems with his memory. Socially, it was noted that the Veteran had a positive relationship with his girlfriend of 10 years, his daughter, and his parents. He also reported having friends. Occupationally, it was reported that the Veteran had not returned to work following his deployment primarily because of physical limitations and financial benefits. Suicidal ideation was denied. A GAF of 65 was assigned. A November 2008 VA treatment note noted that the Veteran was experiencing sleep impairment, nervousness, and irritability. A GAF of 48 was assigned. In January 2009, the Veteran was seen for a supportive therapy and medication management visit. During the visit, the Veteran noted that he was experiencing nightmares one to two times a week. A GAF of 50 was assigned. In treatment records dated in July 2009 and August 2009, the Veteran reported hypervigilance, nightmares, and irritability. The Advanced Practice Registered Nurse (APRN) who was treating the Veteran, noted that the Veteran's speech was clear, his thoughts were organized, and he had no suicidal or homicidal intent. The Veteran also reported stress due to his having to take care of his mother and perform her activities of daily living for her. It was also noted that the Veteran was taking care of his grandchild. A GAF of 60 was assigned for both visits. See VBMS CAPRI December 2015, pg. 770, 774. In December 2009, the Veteran reported hypervigilance, nightmares, irritability, sleep impairment, and issues with his memory. The APRN noted that the Veteran's speech was normal, his thoughts were organized, and he had no suicidal or homicidal intent. She assigned a GAF of 50. See VBMS CAPRI December 2015, pg. 719. A December 2009 letter from a private licensed psychological associate noted that after military service in Iraq, the Veteran began experiencing hypervigilance, problems with memory and concentration, and exaggerated startle responses. The examiner reported that at the time of the examination, the Veteran was hypervigilant, suspicious, avoided crowds, did not socialize, and felt as though he was being watched. He also continued to have problems with memory and concentration, and had an exaggerated startle response. He had intrusive thoughts, nightmares, and difficulty staying asleep. The examiner assigned a GAF of 37. The examiner noted that the Veteran's symptoms "have caused significant disturbances in all areas" of the Veteran's life, and ultimately concluded that "I consider him to be totally and permanently disabled." In treatment records dated in January 2010 and April 2010 the Veteran reported nightmares and irritability. The APRN noted that the Veteran's speech was normal, his thoughts were somewhat tangential, and he had no suicidal or homicidal intent. A GAF of 40 was assigned for both visits. See VBMS CAPRI December 2015, pg. 700, 706. In September 2010, the Veteran was uneasy and reported that he had nightmares, experienced avoidance, hyper arousal, and depression. He also reported fatigue from being the sole caregiver of his mother. The APRN noted that the Veteran's speech was normal, his thoughts were organized, and he had no suicidal or homicidal intent. She assigned a GAF of 38. See VBMS CAPRI December 2015, pg. 674. In October 2010, the APRN wrote a letter that the Veteran was experiencing symptoms such as nightmares, hypervigilance, irritability, depression, insomnia, and difficulty with concentration. In December 2010, it was noted that the Veteran had heard a persistent auditory hallucination during a period of stress, but that it only lasted for one day. He also reported nightmares, depression, and irritability. The APRN noted that the Veteran's speech was normal and he had no suicidal or homicidal intent. She assigned a GAF of 38. See VBMS CAPRI December 2015, pg. 655. On May 7, 2011, the Veteran underwent a VA PTSD examination. The examiner found that the Veteran had a flattened affect, difficulty understanding complex commands, irritability, moderate to severe memory loss, chronic sleep impairment, anxiety, and suffered panic attacks. It was also noted that the Veteran had difficulty in establishing and maintaining relationships. The examiner found that the Veteran's symptoms caused occupational and social impairment, however the examiner also noted that the Veteran stopped working at his previous job after the plant where he worked was shut down. The Veteran denied any problems with supervisors or co-workers. A GAF of 60 was assigned. On May 26, 2011, it was noted that the Veteran had been in a car accident which caused an increase in his anxiety, depression, and social isolation. The APRN noted that the Veteran's speech was pressured, his thoughts were somewhat tangential, and he had no suicidal or homicidal intent. She assigned a GAF of 38. See VBMS CAPRI December 2015, pg. 627. In October 2011, the Veteran's mother passed away and it was reported that most of the Veteran's PTSD symptoms were now worse; however, the symptoms were not noted. The APRN noted that the Veteran's speech was normal and he had no suicidal or homicidal intent. She assigned a GAF of 40. See VBMS CAPRI December 2015, pg. 568. In treatment records dated in December 2011, February 2012, March 2012, June 2012, September 2012, and December 2012, the Veteran reported continued grief and sadness over his mother's death. During this time the Veteran also reported experiencing symptoms such as social isolation, anxiety, depression, irritability, low motivation, and issues with his memory. At times the Veteran's mood would improve. The APRN noted that the Veteran's speech was normal, his thoughts were organized, and he had no suicidal or homicidal intent during his visits. GAF scores ranging from 42 to 48 were assigned during these visits. See VBMS CAPRI December 2015, pg. 556, 521, 489, 465, 423. In March 2013, the Veteran reported less grief related to his mother's death. The Veteran reported decreased mood, sadness, and sleep impairment due to financial circumstances. The APRN noted that the Veteran's speech was normal. She assigned a GAF of 45. See VBMS CAPRI December 2015, pg. 412. In August 2013 the Veteran underwent a VA PTSD examination. The examiner found that the Veteran experienced a depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation or mood, and difficulty in adapting to stressful circumstances. The examiner noted that the Veteran was in a 10 year relationship, had a good relationship with his daughter and step daughter, spoke to his father weekly, and got along with his extended family. No suicidal or homicidal intent was noted. The examiner opined that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. A GAF of 55 was assigned. The examiner also noted that the objective testing that was performed during the Veteran's 2008 VA PTSD examination scored significantly lower than individuals with dementia and that the Veteran's current presentation appeared inconsistent with dementia. An October 2015 correspondence noted that the Veteran experienced difficulty in establishing and maintaining effective work and social relationships, difficulty with impulse control, irritability, outbursts of anger, concentration issues, and chronic insomnia. It was also noted that the Veteran's symptoms had limited him socially and occupationally. It was not noted as to the extent of the limitation. See February 2016 treatment record. A December 2015 VA examination found that the Veteran was experiencing anxiety, suspiciousness, and chronic sleep impairment. Socially it was noted that the Veteran had a good relationship with his family. Occupationally it was noted that the Veteran was not employed due to his medical problems, which included non-service connected back issues. The examiner opined that the Veteran's PTSD resulted in 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 medication. In compliance with the Board's September 2015 remand, the examiner determined that the Veteran's GAF score would be 65. The examiner noted that while the Veteran was polite and compliant during the interview and testing, performance on objective psychological testing indicated that the Veteran had made efforts to intentionally mislead examiner regarding severity of symptoms and impairment. The examiner further stated that the Veteran appeared to put forth poor effort during the mental status examination and appeared to be a poor informant. The examiner found that on a self-administered screening, the Veteran endorsed an unusual number of affective, psychotic, neurological, low intelligence, amnestic, and total symptoms suggesting that he may have embellished his self-report on these domains. The Veteran also completed a measure to further assess accuracy of his performance on cognitive testing; the examiner found that the Veteran's performance on that test indicated clear and unmistakable malingering of memory deficits. The Veteran performed significantly below chance on all trials which the examiner found was inconsistent with actual cognitive impairment, but was consistent with malingering of cognitive impairment. The examiner also noted that no objective testing was performed during the Veteran's last examination in August 2013. Prior to May 26, 2011 The Board finds that the lay statements, VA treatment records, and VA examinations demonstrate that the Veteran's overall disability picture is consistent with a 50 percent rating throughout this period. Based on the most probative of evidence throughout the entire period on appeal, the Veteran has maintained a history of symptoms that predominantly includes anxiety, suspiciousness, chronic sleep impairment, flatted affect, difficulty understanding complex commands, and impairment of the memory. The Board finds that these symptoms and the social and occupational effects related thereto support a 50 percent evaluation prior to May 2011. See Vazquez-Claudio, 713 F.3d at 118. The Board finds, however, that the Veteran is not entitled to a higher rating during this period, as occupational and social impairment with deficiencies in most areas is not more nearly approximated. The Veteran consistently denied suicidal ideation or homicidal ideations. While the Veteran did experience an auditory hallucination, it was noted that it was not persistent and was only noted to have occurred once. The Veteran was also fully oriented throughout the relevant time period. While memory loss has been noted, VA treatment providers and examiners have not indicated that the Veteran had memory loss of names of close relatives, his own occupation, or his own name or neglect of personal appearance and hygiene. A 50 percent rating accounts for impairment of short and long term memory. Additionally, not only was the Veteran able to his perform activities of daily living, he performed his mother's as well. Overall, the Veteran has not demonstrated symptoms consistent with or approximating the general level of impairment warranting a 70 percent or higher evaluation or akin to the symptoms as found in the rating criteria. Mauerhan, supra. Therefore, the Board finds that the Veteran's PTSD warrants an initial 50 percent rating for the period prior to May 27, 2011. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board also notes the December 2009 letter from the psychological associate in which she described the Veteran as having a GAF of 37 and being "totally and permanently disabled." The Board places very low probative weight on the assessment of the private psychology associate in her letter from December 2009. The associate's examination reports and clinical notes consisted primarily of a recitation of the Veteran's reported history and symptoms and another recitation of the PTSD diagnostic criteria. The assignment of a diagnosis was conclusory with little explanation or rationale, with a minimal discussion of a mental status examination, and no reference to any standardized testing. The associate made findings of severe social and occupational impairment with little reference to specific examples. The associate did not discuss the nature of the occupational impairment. There was no indication that the associate had reviewed the Veteran's claims file. There was no discussion of any therapy or recommendations for the patient to mitigate the symptoms. Moreover, the description of the social impairment was inconsistent with the Veteran's report to the VA examiner in December 2008 of relationships with family and friends. The Board assigns little probative weight to the letter as it does not provide thorough clinical assessments or details of the therapy. Additionally, the Board acknowledges that the Veteran has been assigned GAF scores ranging from 38 to 65 by an APRN. Although the same provider recorded GAF scores of 38 and 40, reflecting significant impairment in January 2010, April 2010, September 2010, and December 2010 treatment notes, the Board notes that the symptoms recorded therein are unsupportive of a 70% rating. A GAF score of 31 to 40 indicates that the examinee has some impairment in reality testing or communication, such as illogical, obscure, or irrelevant speech, or that the examinee has major impairment in social, occupational, or school functioning. During these visits it was consistently noted that the Veteran's speech was either clear or normal and it does not appear as if the Veteran's commination was impaired. Socially, it was noted that the Veteran cared for his mother and also functioned as her sole caregiver. Additionally, in each note the APRN found that the Veteran was dressed appropriately, had fair insight, and fair judgement. Symptoms such as nightmares, irritability, avoidance, and depression were noted which are akin to a disability rating of 30 percent, rather than 70 percent, during these visits. While considering the GAF scores as part of the overall social and occupational functioning picture, the Board finds the narratives contained in the treatment records and the VA examiners' identification of symptomatology to be the most probative evidence of the Veteran's psychological state during the relevant period. The preponderance of the most probative evidence is against the assignment of a higher initial rating for the PTSD prior May 2011. Unfortunately, the findings needed for a higher evaluation were not demonstrated. Since the preponderance of the evidence is against an allowance of an evaluation in excess of 50 percent for PTSD the benefit-of-the-doubt doctrine is inapplicable. 38 U.S.C. § 5107(b); Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Although the Board is appreciative of the Veteran's faithful and honorable service to our country, given the record before it, the claim for an increased rating for the period prior to May 26, 2011 must be denied. After May 26, 2011 Affording the Veteran the benefit of the doubt, the Board finds that the lay statements, VA treatment records, and VA examinations demonstrate that the Veteran's overall disability picture is consistent with a 70 percent rating after May 27, 2011. The Veteran has maintained a history of symptoms that predominantly includes difficulty in adapting to stressful circumstances and near continuous depression. The Board finds that these symptoms and the social and occupational effects related thereto support a 70 percent evaluation for this period. See Vazquez-Claudio, 713 F.3d at 118. More specifically, the record indicates that the Veteran's PTSD symptoms began to increase in May 2011 after he had been involved in a car accident. This is indicative of difficulty in adapting to stressful circumstances. An August 2013 VA examiner also noted the Veteran's difficulty in adapting to stressful circumstances Furthermore, when the Veteran's mother passed away in October 2011, the Veteran entered a period of grief that lasted until August 2013. This is akin to a near continuous depression. The frequency, severity, and duration of the PTSD symptoms such difficulty in adapting to stressful circumstances and near continuous depression more closely approximate the criteria for a 70 percent evaluation. In rendering this determination, the Board acknowledges that there is evidence of record that does not support an increased rating. In particular, the August 2013 VA examiner indicated that the Veteran's symptoms of PTSD resulted in occupational and social impairment with reduced reliability and productivity. The Board finds the narratives contained in the treatment records, the lay evidence, and the VA examiner's description of symptoms to be the most probative evidence of the Veteran's psychological symptomatology. Additionally, the December 2015 examiner suggested that the Veteran's reporting of symptoms was inaccurate; however, the examiner also acknowledged that "individuals who present with inaccurate self-report of symptoms may very well have mental health symptoms that are clinically significant and distressing." Although the Board has no reason to question the examiner's methodology to test feigned PTSD symptoms, it is unclear whether the exaggeration of symptoms is, in and of itself, a symptom of the Veteran's psychiatric syndrome. In contrast to the negative report, separate mental health professionals have consistently described the Veteran's symptoms during this period. Specifically, the Veteran's treatment records from May 2011 to October 2015 do not report any suspected malingering during this period. In sum, resolving all doubt in favor of the Veteran, the Board finds that the impairment caused by the Veteran's PTSD symptoms more nearly approximate occupational and social impairment with deficiencies in most areas from after May 26, 2011. Thus, a 70 percent rating is warranted. The Board finds, however, that the Veteran is not entitled to a higher rating during the appeal period, as total occupational and social impairment has not been noted. Notably, the Veteran remained in a relationship with his girlfriend, had a good relationship with his daughter and step-daughter, spoke to his father weekly, and reported being very attached to his granddaughter. The Veteran has consistently denied suicidal ideation, delusions, and hallucinations during this period. He was also fully oriented throughout the relevant time period. VA treatment providers and examiners have not indicated that the Veteran had memory loss of names of close relatives, his own occupation, or his own name or neglect of personal appearance and hygiene. Additionally, the Veteran was able to perform activities of daily living. Overall, the Veteran has not demonstrated symptoms consistent with or approximating the general level of impairment warranting a 100 percent evaluation or akin to the symptoms as found in the rating criteria. Mauerhan, supra. Therefore, the Board finds that the Veteran's PTSD warrants a 70 percent rating for this period. See 38 C.F.R. § 4.130, Diagnostic Code 9411. II. TDIU 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 (2017). 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) (2017). To meet the requirement of "one 60 percent disability" or "one 40 percent disability," the following will be considered as one disability: (1) disability of one or both lower extremities, or one or both upper extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). 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 (2017). As of May 8, 2009, the Veteran is service-connected for PTSD, rated at 50 percent disabling; sleep apnea, rated at 50 percent disabling; right leg phlebitis, rated at 10 percent disabling; and hypertension, rated at 0 percent disabling; for a combined evaluation of 80 percent. As such, the Veteran meets the "40 percent or more disability with sufficient additional service-connected disability to bring the combination to 70 percent or more" requirement for TDIU. 38 C.F.R. § 4.16(a). The Board must now consider whether the evidence reflects that the Veteran's service-connected disabilities render him unemployable. The lay and medical evidence in this case demonstrate that the Veteran's service connected disabilities do not allow the Veteran to obtain or retain substantially gainful employment. In the Veteran's October 2011 Application for Increased Compensation Based on Unemployability, the Veteran indicated that he had not worked since 2007 when his active duty service ended. The Veteran reported that he had obtained his GED. A May 2011 VA examination found that the Veteran had worked in a warehouse and as a janitor prior to his active service. In July 2008 a VA examiner noted that the Veteran's right leg phlebitis caused significant effects on occupation. In December 2008 a VA examiner noted that Veteran's PTSD caused limited occupational impairment. The examiner could not determine the extent of the impairment due to the Veteran's current unemployment. The Veteran reported that he did not return to work due to his physical disabilities and the stress that work might cause him to experience. In May 2011 a VA examiner noted that the Veteran's PTSD caused occupational impairment. The extent of the impairment was not discussed. In August 2013 the Veteran underwent a VA PTSD examination. The examiner found that the Veteran experienced difficulty in adapting to stressful circumstances. The examiner opined that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. An October 2015 correspondence noted that the Veteran's PTSD symptoms limited him occupationally by making it difficult to maintain connections with people and employment. The Board finds that the Veteran's service-connected disabilities prevent him from obtaining and maintaining substantially gainful employment, as the Veteran's problems make employment that is suitable for him extremely challenging. As previously stated, the Veteran's highest level of education is a GED and he has only worked in jobs that require physical labor, however, his right leg phlebitis has caused significant effects on occupational viability and his PTSD resulted in him being unable to maintain the connections that result in employment. This, coupled with the Veteran's difficulty in adapting to stressful circumstances, results in the Veteran not being able to obtain and maintain substantially gainful employment. The Veteran is unlikely to find an occupation that is similar to his previous work due to his service-connected disabilities. Thus, affording the Veteran the benefit of the doubt, the Veteran's service-connected disabilities make it impossible for the Veteran to follow a substantially gainful occupation. As such, the Board concludes that entitlement to TDIU is warranted. ORDER Entitlement to an initial rating in excess of 50 percent for PTSD prior to May 26, 2011 is denied. Entitlement to a disability rating of 70 percent for PTSD after May 26, 2011 is granted. Entitlement to TDIU is granted. ______________________________________________ A. S. CARACCIOLO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs