Citation Nr: 1808139 Decision Date: 02/08/18 Archive Date: 02/20/18 DOCKET NO. 14-19 779A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to an increased disability rating in excess of 70 percent for post-traumatic stress disorder with major depression (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION The Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Grace J. Suh, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1969 to March 1971, during the Vietnam Era. For his service, he received the National Defense Service Medal, Vietnam Service Medal with two bronze stars, Vietnam Campaign Medal with 1960 device; Combat Infantry Badge; Army Commendation Medal with V device and two oak leaf clusters; and Purple Heart. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In June 2016, the Veteran testified before the undersigned Veterans Law Judge at a Board hearing in Washington, D.C.; a transcript has been associated with the claims file. FINDINGS OF FACT 1. Prior to June 1, 2011, the Veteran's PTSD was primarily manifested by depressed mood; anxiety without panic attacks; intermittent suicidal ideation; impaired impulse control, without attendant violence; sleep impairment; and mild memory loss. 2. From June 1, 2011, the Veteran's PTSD was primarily manifested by fluctuations in mood; persistent auditory hallucinations; infrequent visual hallucinations; intermittent suicidal ideation; and impaired impulse control akin to unprovoked irritability with periods of violence. 3. From February 28, 2014, the Veteran's PTSD was primarily manifested by fluctuations in mood; persistent auditory hallucinations; infrequent visual hallucinations; and impaired impulse control akin to unprovoked irritability with periods of violence. 4. Prior to June 1, 2011, the occupational impairment resulting from the combination of the Veteran's service-connected disabilities prevented him from securing or following substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating in excess of 70 percent for PTSD have not been met prior to June 1, 2011. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). 2. The criteria for an increased disability rating of 100 percent for PTSD from June 1, 2011 to November 18, 2013, and from February 28, 2014 have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.126, 4.130, DC 9411. 3. The criteria for TDIU have been met prior to June 1, 2011. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19, 4.25 (2017). 4. The criteria for special monthly compensation (SMC) in accordance with 38 U.S.C. § 1114(s) (2012) have been met from June 1, 2011. 38 C.F.R. §§ 3.350(i), 4.25 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Disability Rating for PTSD The Veteran contends that he is entitled to an increased disability rating in excess of 70 percent for PTSD prior to November 18, 2013, and from February 28, 2014. See July 2011 Statement in Support of Claim. Preliminarily, the Board notes the applicable DC is 9411, which is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. §§ 4.27, 4.130. Under the General Rating Formula for Mental Disorders, a 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgement, thinking, or mood, due to symptoms such 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 work-like setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted 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; and, memory loss for names of close relatives, own occupation, or own name. The Board acknowledges the psychiatric symptoms listed in the rating criteria are not exhaustive, but are examples of typical symptoms for the listed disability rating. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013); see also Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). While the use of Global Assessment of Functioning (GAF) scale has been discontinued under American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM 5), because the Veteran's medical records of evidence contained evaluations conducted in accordance with the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), the Board will consider them. In doing so, the Board is mindful of the fact that although a medical professional's assignation of a GAF score may be probative evidence of the veteran's degree of disability; it is not determinative of the disability rating to be assigned. See VAOPGCPREC 10-95 (March 31, 1995). The GAF scale ranges from zero to 100, and reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See DSM IV. A GAF score of 60 to 51 indicates there are moderate symptoms, or moderate difficulty in social, occupational, or school functioning; and 50 to 41 indicate there are serious symptoms, or serious impairment in either social, occupation, or school functioning. As in this instance, where an increase in the disability rating assigned is at issue, the primary concern is the Veteran's present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994); cf. Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, if factually ascertainable, the effective date assigned may be up to one year prior to the date the application for increase was received. 38 U.S.C. § 5110 (2012). As he has already been assigned a 100 percent disability rating from November 18, 2013 to February 27, 2014, the relevant timeframes for consideration are from August 1, 2010 to November 17, 2013, and from February 28, 2014 to the present. See July 2011 Statement in Support of Claim (the Veteran initiated a claim for an increased disability rating for PTSD, which was received by the VA on August 1, 2011). Generally, in assessing the evidence of record, the Board acknowledges the Veteran and his wife are competent to provide evidence regarding the lay observable symptoms of his PTSD. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that while a lay person is not competent to opine as to medical etiology or render medical opinions, they are competent to establish the presence of observable symptomatology) abrogated on other grounds by Walker v. Shinseki, 708 F.3d 1331 (2013). However, as their statements relate to a clinical assessment of occupational or social impairment, the Board is unable to accord them any probative weight because neither is competent to render a medical diagnosis or opinion on such a complex medical question. See Barr, supra; see also Jones v. West, 12 Vet. App. 460, 465 (1999) (holding that only those with specialized medical knowledge, training, or experience are competent to render a medical diagnosis). In that regard, the Board finds the medical evidence of record most probative. First the Board examines whether an increased disability rating in excess of 70 percent for PTSD prior to November 18, 2013 can be supported. A review of the claims file is devoid of any relevant medical evidence from August 1, 2010 until the Veteran's VA examination in April 2011. During the April 2011 VA examination, he reported being married to his wife for 23 years. April 2011 PTSD VA Examination Report. He stated he was his wife's caregiver because she had been diagnosed with a neurological problem. While he had five adult children, he did not have a relationship with two of them, and he described his relationship with the other three as fair. However, he relayed having a good relationship with his in-laws as well as his two older sisters. He also had a friend from a coping skills class, but stated they have not spoken in several months. He mostly kept to himself because he becomes easily irritated. He disclosed he was receiving psychiatric treatment through the VA and was taking medications for his psychiatric symptoms. He retired from the Unites States Postal Service (USPS) after more than three decades, and was presently not working. Generally, the VA examiner observed the Veteran presented neatly and casually dressed. He was alert and oriented and exhibited appropriate. His speech was within normal limits. There was no evidence of impairment of his thought processes or communication. While he reported having thoughts of jumping off a bridge two weeks earlier, at the time of examination, there was no evidence of suicidal or homicidal ideation, delusions, or hallucinations. However, his mood was depressed and there was evidence of continuous depression. Even though there was evidence of anxiety, there was no evidence of panic attacks. There was also evidence of impaired impulse control, without attendant violence; sleep impairment; and memory loss, such as forgetting appointments. Overall, the VA examiner opined his symptoms were chronic and continuous, without remissions, but moderate in severity. The VA examiner assigned a GAF score of 50, indicating he exhibited serious symptoms resulting in serious impairment in either social, occupation, or school functioning. Following the April 2011 VA examination, the Veteran's VA treatment records disclose that in June 2011, he endorsed experiencing suicidal ideation between one and two times per week, with thoughts of bashing his head. June 1, 2011 VA Psychiatric Note. Additionally, he suffered from audio hallucinations once per week; voices told him things like "get revenge for me." The treatment provider concluded that he was intermittently suicidal, but was not an imminent danger of harming himself or others. He continued to report irritability, depressed mood, low motivation, and low energy. Subsequently, a September 2011 VA Psychological Assessment noted the Veteran had experienced manic symptoms in June due to a higher dosage of his psychiatric medications; symptoms such as racing thoughts, auditory hallucinations, and distractibility. Even though he denied any suicidal ideation during this appointment, he continued to report depressed mood. He also complained of poor concentration, poor energy, and anhedonia. September 2011 VA Psychological Assessment. A September 2011 VA Addendum documented the Veteran's wife's report that he was withdrawn, irritable, angry, and hostile. Their relationship was distant. September 2011 VA Addendum. She stated he has been verbally abusive throughout their marriage. While he threatens physical harm, he has never followed through. By the end of the year, the Veteran's symptoms were not improved. He reported having arguments with his wife. He felt worthless at times and had thoughts that he did not care if he was dead. However, he did not have any intent to act on those thoughts. He relayed feeling non-specific anger, but denied any homicidal ideation. He described experiencing audio hallucinations; voices telling him things like "you aren't going to let anyone run over you are you?" The treatment provider noted his grooming and hygiene were fair. He was cooperative as well as alert and oriented. His mood was down and affect was a little restricted. Even so, his speech was within normal limits; thought processes were linear; insight and judgement were fair. According to the Veteran's VA treatment notes from 2012, throughout the year he continued to take medications for his psychiatric symptoms. However, he did not always take his medication as prescribed. For instance, a January 2012 VA Mental Health Note revealed that he had inadvertently taken less than the prescribed dosage of medication. Nevertheless, there was no appreciable increase in the severity of his symptoms. He stated still had difficulty getting along with his wife. His mood and affect were noted to be restricted. Even so, he was observed to be cooperative as well as alert and oriented. His speech was within normal limits. Despite his thoughts of worthlessness, there was no evidence suicidal or homicidal ideation, or delusions. His thought processes were linear. His insight and judgment remained fair. In April 2012, he admitted that he was not taking his medication for mood. Even still, he reported that his mood was "pretty good." April 2012 VA Mental Health Note. For the most part in 2012, the Veteran relayed fluctuating mood. At times, he exhibited a restricted affect. Intermittently he continued to endorse suicidal ideation without any intent to act on it as well audio hallucinations. While generally, his audio hallucinations did not include commands to harm others, a September 2012 VA Mental Health Note recorded hearing voices that told him to harm others. However, he asserted that he was able to resist acting on it. Additionally, he reported experiencing a visual hallucination a year earlier. Sometimes, he wondered if someone else was in the room with him. See May 2012 VA Mental Health Note. Each VA treatment record from 2012 documented the Veteran presented with appropriate grooming and hygiene; was alert and oriented; demonstrated speech within normal limits; exhibited linear thought processes; and displayed fair insight and judgment. In terms of a GAF score, in a November 2012 VA Mental Health Note and December 2012 VA Mental Health Treatment Plan the treatment providers assigned a GAF score of 55, indicating his symptoms were moderate in severity. The same GAF score was assigned until May 2013. See January 2013 VA Mental Health Note; February 2013 VA Mental Health Note; March 2013 VA Mental Health Note; May 2013 VA Mental Health Note. Until November 18, 2013, the VA treatment notes from 2013 reveal, the Veteran continued to take medications for his psychiatric symptoms. Despite the medications, his mood continued to fluctuate. He still had problems communicating with his wife. He experienced intermittent suicidal ideation without any intent to act on it. He also continued to experience audio hallucinations. For the most part, the audio hallucinations did not contain commands to harm others. However, a May 2013 VA Mental Health Note indicated sometimes the voices told him to harm others. The Veteran was examined once more by the VA in May 2013. See May 2013 PTSD VA Examination Report. During this examination he relayed that he was still married, but his relationship with his wife was "off and on." He had a good relationship with his adult son, but had limited contact with his three adult daughters. Although the Veteran continued taking his psychiatric medication, he described suffering from moderate to severe depression and PTSD symptoms. He just felt "down." His sleep was impaired due to nightmares two to three times per week. He slept for about three hours per night, and felt tired during the day. He had intrusive thoughts; concentration was decreased; continued hypervigilance; and an exaggerated startle response. Emotionally, he was numb and detached. He started attending a recreation group, but had only been to a couple of session. He experienced increased irritability and continued anger problems. He admitted that he lashed out at people and had thoughts about what he would like to do to people who irritate him. However, he does not act on these thoughts. He still had suicidal ideation; thoughts of driving off a bridge. He continued to have auditory hallucinations a few times per week. The VA examiner identified the Veteran's current psychiatric symptoms were depressed mood, anxiety, suspiciousness, panic attacks weekly or less; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; difficulty establishing effective and social relationships; suicidal ideation; impaired impulse control, such as unprovoked irritability with periods of violence; persistent delusions or hallucinations. Despite noting symptoms consistent with a 100 percent disability rating, the VA examiner opined these symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. In contemplating the evidence above, the Board finds the preponderance of the evidence supports an increased disability rating of 100 percent from June 1, 2011 to November 17, 2013 for his PTSD. 38 C.F.R. § 4.130, DC 9411. However, prior to June 1, 2011, the Board finds the preponderance of the evidence is against an increased disability rating in excess of 70 percent. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (2009). The Board acknowledges the Veteran was on psychiatric medication throughout the relevant time period. As such, the Board is mindful of the fact that a higher disability rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). However, a review of the claims file reveals he was not always compliant with his medication regimen. Despite his occasional non-compliance, they did not necessarily correlate with an increase in the severity of his symptomatology. See January 2012 VA Mental Health Note; April 2012 VA Mental Health Note; May 2012 VA Mental Health Note. In fact, on at least once occasion the evidence of record suggests the dosage of his medication resulted in an increase in the severity of his symptoms. See September 2011 VA Psychological Assessment. When he was compliant with his medications, the evidence of record indicates varying levels of efficacy. See May 2013 VA Mental Health Note; September 2014 VA Mental Health Note; November 2014 VA Mental Health Note. Therefore, the Board must consider an weigh the entirety of the evidence available during this period. Prior to June 1, 2011, even though the Veteran reported having thoughts of jumping off a bridge two weeks prior to the VA examination, the VA examiner found no evidence of continued suicidal ideation. April 2011 PTSD VA Examination Report. Further, the VA examiner concluded there was no evidence of homicidal ideation, delusions, or hallucinations. Although there was evidence of impaired impulse control, the VA examiner specifically found it was not accompanied by violence. As such, during this period, there is no evidence of record showing he was a persistent danger to either himself or others. Therefore, to the extent he had suicidal ideation, it is sufficiently addressed by the 70 percent disability rating. While the VA examiner determined the Veteran's memory was impaired, it did not rise to the level of memory loss of names of close relatives, own occupation, or own name. Rather, he exhibited mild memory, such as forgetting appointments, which is encompassed by a 30 percent disability rating. Despite the fact the Veteran suffered from continuous depression as well as anxiety, there was no evidence of panic attacks. More importantly, he maintained the ability to function independently, appropriately, and effectively. He presented neatly and casually dressed; demonstrated appropriate behavior; was alert and oriented; speech was within normal limits; and there was no impairment of thought processes. Notably, he reported that he was his wife's caregiver because she had been diagnosed with a neurological problem. At no time prior to June 1, 2011, did the Veteran manifest any symptoms typically associated with a 100 percent disability rating for PTSD, or symptoms of a similar severity or frequency. See Vazquez-Claudio, supra; see also Mauerhan, supra. In contrast, beginning in June 1, 2011 through November 17, 2013, the evidence of record establishes the Veteran began experiencing auditory hallucinations. While the June 1, 2011 VA Psychiatric Note documented his report that these auditory hallucinations occurred once per week, during the May 2013 VA examination he stated they occurred a few times per week. Even though for the most part his auditory hallucinations did not consist of commands to harm other people, on a few occasions he admitted voices told him to hurt others. A May 2012 VA Mental Health Note suggested the Veteran may have experienced visual hallucinations as well; he relayed wondering if someone else was in the room with him. Subsequently, a November 2012 VA Mental Health Note indicated he described vague visual hallucinations about a year earlier around the time he had magnetic resonance imaging conducted of his brain. In addition to hallucinations, the Veteran continued to experience intermittent suicidal ideation. By the time of the May 2013 VA examination, the VA examiner found the severity of the Veteran's impaired impulse control had increased. While he did not relay any actual acts of violence accompanying his irritability or anger, the VA examiner assessed it approximated the severity level of impaired impulse control was on par with unprovoked irritability with periods of violence. Next the Board determines whether an increased disability rating in excess of 70 percent for PTSD from February 28, 2014 can be substantiated. A review of the claims file produces limited medical evidence pertinent to this time period. Following the Veteran's inpatient hospitalization from November 18, 2013 to February 14, 2014 due to his PTSD, his symptoms seemingly improved. A September 2014 VA Mental Health Note documented his report that his mood was not too bad despite forgetting to take his afternoon psychiatric medications about 10 times in the past month. However, he experienced intermittent periods of sadness. While he relayed that he was having difficulty with his wife and children, he stated his mother-in-law was emotionally supportive and he had a couple of friends. Although he heard voices, he could not tell whether they were vivid memories or audio hallucinations. The last time he heard voices was a week before. He denied any visual hallucinations. The treatment provider observed he presented with good hygiene; was cooperative, alert, and oriented; had full range of affect; no impairment of speech; no impairment of thought processes or content; and insight and judgment were good. Notably, there was no suicidal or homicidal ideation reported. A November 2014 VA Mental Health Note recorded the Veteran's report of having a passive death wish, but without plans to act on it. He stated that he has been taking care of his wife, who had surgery. Even so, he continued to have a strained relationship with her as well as his children. However, he reported that he was looking forward to a having a large Thanksgiving with extended family. The treatment provider's observations were consistent with those from September 2014. Of note, despite his report of passive thoughts of death, the treatment provider found no evidence of suicidal or homicidal ideation at the time of the appointment. The Veteran's 2015 VA treatment records suggest his symptoms were improved. While his mood still fluctuated between average and "not too good," his affect was noted to be stable ranging from mild irritable, restricted, reactive, to average. He continued to relay having a difficult relationship with his wife. Nevertheless, his treatment provider consistently found no evidence of speech impairment; impairment of thought processes; suicidal or homicidal ideation; or perceptual disturbances. His insight and judgement were fair. The Veteran's 2016 VA treatment records largely reiterated the 2015 findings, with the exception of noting he exhibited a generally "weary" mood and a mildly restricted or reactive affect. While the Veteran was not examined by the VA during the relevant period, he and his wife testified at a June 2016 Board hearing in Washington, DC. See June 2016 Board Hearing Transcript. With respect to his PTSD symptoms, he testified that he is unable to stay on track. Id. at 5. He begins one thing and starts another without completing it; things like cleaning his car and mowing the lawn. Id. at 4, 5. His wife confirmed his testimony. Id. at 5. She expressed her frustration with the fact that he begins something and all of a sudden wonders if he finished it. The Veteran's wife relayed they had difficulty communicating with each other, and it has worsened over time. Id. at 7. She testified that when they get fed up with each other he tells her that he is just going to talk to their dog. The Veteran continued to experience hearing voices. He claimed they were voices of his men who died in combat. They tell him that they look out for him and have his back. Sometimes, he has conversations with these voices. Id. at 8. He also relayed occasional visual hallucinations. The Veteran described an incident with his first wife during which he argued with her and took a pistol and shot it in her direction. Id. at 9. While he has not acted out again to this degree, he admitted to experiencing the urge to do so many times. Further, he testified that he would still hit somebody if they crossed his path. Id. at 13. The Veteran continued to receive mental health treatment through the VA. Id. at 13. However, he qualified that they were more like maintenance checks and were 15 minutes in duration. Id. at 14; cf. generally VA Mental Health Notes from 2014 through 2017 (the treatment sessions were 30 minutes in length). According to his wife, these sessions were not doing anything to help him. June 2016 Board Hearing Transcript at 15. She stated things were getting worse and worse at home. Id. at 14. The Veteran's wife recalled a flashback he had with an Asian woman on one occasion, but did not specify when this incident occurred. Id. at 16. During the flashback, he threatened to kill the woman. Id. at 17. She did not speak to him for two weeks after the incident because it scared her so badly, but he did not remember anything about it. Id. at 16. She was scared to the point she asked her parents to move in with them. When the Veteran slept, the Veteran's wife described he fought, hollered, screamed, and moaned; and she gets hit, kicked, and slapped. Id. at 17. By 2017, a VA Mental Health Note recorded the Veteran's report that things have been up and down. Consistent with his wife's testimony during the June 2016 Board hearing that their relationship was deteriorating and things were just getting worse and worse at home, he relayed that he was no longer living with her. Even so, he stated he enjoyed celebrating his father-in-law's birthday. Again, his treatment provider found no evidence of speech impairment; impairment of thought processes; suicidal or homicidal ideation; or perceptual disturbances. His insight and judgement remained fair. His affect was noted to be calm and stable. While the limited medical evidence available does not corroborate the persistent nature of the Veteran's audio hallucinations, the Board notes during this timeframe, he remained on psychiatric medications without any indication of side effects or non-compliance. In 2014, his treatment provider determined they were partially effective. See September 2014 VA Mental Health Note; November 2014 VA Mental Health Note. Whereas, in 2015, 2016, and 2017, his treatment provider determined they were effective. Unlike before, there is an appreciable difference the symptomatology depending on the effectiveness of the medications. When the medications were partially effective, he continued to report auditory hallucinations and passive suicidal ideation. In view of the Veteran's and his wife's testimony during the June 2016 Board hearing and the fact that a disability rating may not be denied on the basis of relief provided by medication, the Board finds the preponderance of the evidence warrants an increased disability rating of 100 from February 28, 2014. 38 C.F.R. § 4.130, DC 9411; see also Jones v. Shinseki, 26 Vet. App. at 63. II. TDIU The Veteran contends that he is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. See April 2010 Veteran's Application for Increased Compensation Based on Unemployability; June 2016 Board Hearing Transcript at 18. The Veteran filed a claim for TDIU prior to his claim for an increased disability rating for PTSD. His claim for TDIU was received by the VA on April 22, 2010. See April 2010 Statement in Support of Claim. In light of the Board's award of a 100 percent disability rating for PTSD from June 1, 2011, the relevant timeframe for consideration is from April 22, 2010 to June 1, 2011. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400 (2017). From April 22, 2010 to June 1, 2011, the Veteran was service-connected for PTSD with a 70 percent disability rating; gastroesophageal reflux disease (GERD) with a 30 percent disability rating; ischemic heart disease (IHD) with a 30 percent disability rating effective August 31, 2010; lumbar spine condition with a 10 percent disability rating; and peripheral neuropathy of the left lower extremity with a 10 percent disability rating. See August 2014 Rating Decision Codesheet. Consequently, he met the minimum disability rating percentage threshold for schedular TDIU consideration at all times. 38 C.F.R. § 4.16(a). For TDIU purposes, the sole fact that a veteran is unemployed or has difficulty obtaining employment is insufficient. The evidence must show the veteran is incapable of performing the physical and mental acts required by employment by reason of his service-connected disabilities. See 38 C.F.R. § 4.16(b); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In this context, appropriate factors for consideration are his employment history, educational and vocational attainment, and any other factors having a bearing on the issue. 38 C.F.R. § 4.16(b); see also Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). During the June 2016 Board hearing, the Veteran testified that he worked in a building maintenance position his entire tenure with the USPS. June 2016 Board Hearing Transcript at 19, 30. His position required him to lift, move, and repair things. Id. at 19. Eventually, he was assigned to a warehouse to work alone. Id. at 10, 25. He was kept isolated because he could not stand being around other people and he did not get along with his supervisor. Id. at 19. He was given an opportunity to retire early, and it was suggested that he take it, so he did. Afterward, he tried vocational rehabilitation, but was told that he was unemployable and advised to apply for TDIU. Id. at 26-7. According to the April 2010 Veteran's Application for Increased Compensation Based on Unemployability, the Veteran was employed with the USPS essentially from the time of his separation from service until his retirement in October 2009. He reported obtaining training relevant to his position through the USPS, such as environmental control; electrical; heating, ventilation, and air conditioning; and roof repair. April 2010 Veteran's Application for Increased Compensation Based on Unemployability. However, there is no evidence he obtained any tradesmen licensures as a result of these trainings. In terms of educational attainment, he was only able to earn a high school diploma. Just two months following the Veteran's retirement, a December 2009 VA examiner determined the occupational and social impairments, outside of the Veteran's familial relationships, due to his PTSD were severe. December 2009 PTSD VA Examination Report. At that time, he stated that he missed a significant amount of time from work over the last year because he just did not feel like being there. He missed a week at a time every few months. If he got into an argument with someone or did not want to be around someone he simply left work. In terms the Veteran's physical abilities, in an October 2010 Heart VA Examination Report, a VA examiner concluded he would be unable to perform the physical activities required for a position in building maintenance due to fatigue stemming from his IHD. Further, a stress tested revealed he experienced intermittent angina with a metabolic equivalent (MET) of 3 METs, which is consistent with activities such as mowing the lawn or doing yard work. Only six months later, an April 2011 VA examiner found there was no functional impact on the Veteran's ability work arising from his IHD. April 2011 IHD VA Examination Report. The VA examiner determined he did not report any pain that could be considered anginal. Rather, his chest pains were attributable to his GERD. However, in reaching this decision, the VA examiner relied, at least in part, on a December 2007 exercise test, which was conducted more than three years prior. Thus, the Board attaches less probative weight to the April 2011 IHD VA Examination Report. That same month, the Veteran submitted an April 2011 IHD Disability Benefits Questionnaire (DBQ) from Dr. M.E.C., a private treatment provider. Dr. M.E.C. also referenced the same December 2007 exercise test. While Dr. M.E.C. noted his current report of fatigue of dizziness due to IHD, Dr. M.E.C. failed to indicate the lowest level of activity associated with these symptoms. Despite these symptoms, Dr. M.E.C. concluded his ability to work was not impaired due to his IHD. Based on the foregoing, the Board accords the April 2011 IHD DBQ less probative weight as well. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008). With respect to the Veteran's GERD, in an October 2010 Esophagus and Hiatal Hernia VA Examination Report, a VA examiner opined there was no significant occupational impairment resulting from his GERD. Less than a year later, in an April 2011 Esophagus and Hiatal Hernia VA Examination Report, a VA examiner observed his GERD symptoms seemed more severe than the average person with GERD. This VA examiner concluded the pain and nausea due to GERD had a significant occupational effect; increased absenteeism. In terms of the Veteran's lumbar condition and peripheral neuropathy of the left lower extremity, an April 2011 Spine VA Examination Report documented his report of daily pain in his lumbar region, which radiated down into his legs. The VA examiner found he exhibited limitation of motion with all motions tested; diffuse, decreased sensation to pain or pinprick of the left lower extremity; as well as decreased vibration sense of the left great toe. In the end, the VA examiner opined these disabilities caused functional impairment by creating problems with lifting and carrying due to pain. April 2011 Spine VA Examination Report. Based on the evidence outlined above, the Board finds the occupational impairments stemming from the Veteran's service-connected disabilities in conjunction with his limited educational attainment and work history limited to a single occupational field, which mainly consisted of physical labor warrants the award of TDIU prior to June 1, 2011. Notwithstanding the Board's award of a 100 percent disability rating for PTSD from June 1, 2011, as the VA is required to maximize the benefits awarded to the Veteran, the issue of TDIU from June 1, 2011 has not been fully resolved, because entitlement to special monthly compensation (SMC) has not been addressed. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). SMC is available when a veteran has a service-connected disability rated as total and has an additional disability or disabilities independently ratable at 60 percent or more. 38 U.S.C. § 1114(s) (2012); 38 C.F.R. § 3.350(i). Aside from PTSD, from June 1, 2011, the Veteran has been additionally service-connected for GERD with a 30 percent disability rating; IHD with a 30 percent disability rating; lumbar spine condition with a 10 percent disability rating; and peripheral neuropathy of the left lower extremity with a 10 percent disability rating. See August 2014 Rating Decision Codesheet. The combined disability rating for these service-connected disabilities is 60 percent. 38 C.F.R. § 4.25. Therefore, the criteria for SMC in accordance with 38 U.S.C. § 1114(s)(1) have been met. Consequently, the issue of TDIU from June 1, 2011 is now moot. ORDER An increased disability rating in excess of 70 percent for PTSD prior to June 1, 2011 is denied. An increased disability rating of 100 percent for PTSD from June 1, 2011 to November 18, 2013, and from February 28, 2014 is granted, subject to the governing criteria applicable for the payment of monetary benefits. TDIU prior to June 1, 2011 is granted, subject to the governing criteria applicable for the payment of monetary benefits. SMC in accordance with 38 U.S.C. § 1114(s) from June 1, 2011 is granted, subject to the governing criteria applicable for the payment of monetary benefits. ____________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs