Citation Nr: 20057553 Decision Date: 09/01/20 Archive Date: 09/01/20 DOCKET NO. 14-07 363 DATE: September 1, 2020 ORDER 1. Prior to August 12, 2015, entitlement to an evaluation of 70 percent, but no higher, for service-connected posttraumatic stress disorder (PTSD) is granted. 2. On and after August 12, 2015 and prior to April 18, 2019, entitlement to an evaluation of 70 percent, but no higher, for PTSD is granted. 3. On and after April 18, 2019, entitlement to an evaluation in excess of 70 percent for service-connected PTSD is denied. 4. Entitlement to TDIU is granted prior to April 18, 2019. 5. Entitlement to special monthly compensation (SMC) is granted on and after December 30, 2011 to May 1, 2014. FINDINGS OF FACT 1. Prior to August 12, 2015, the Veteran’s PTSD has been characterized by occupational and social impairment with deficiencies in most areas, but not total social and occupational impairment. 2. From August 12, 2015 to April 18, 2019, the Veteran’s PTSD has been characterized by occupational and social impairment with deficiencies in most areas, but not total social and occupational impairment. 3. After April 18, 2019, the severity, frequency, and duration of the Veteran’s symptoms did not more closely approximate total occupational and social impairment. 4. Prior to April 18, 2019, the Veteran’s combined disability rating met the schedular criteria, and his service-connected PTSD prevented him from following or maintaining a substantially gainful occupation. 5. From December 30, 2011 to May 1, 2014, the Veteran was in receipt of a 100 percent evaluation for service-connected prostate cancer and a 70 percent evaluation for service-connected PTSD. CONCLUSIONS OF LAW 1. Prior to August 12, 2015, the criteria for entitlement to an evaluation of 70 percent, but no higher, for service- connected PTSD are met. 38 U.S.C. §§ 1155, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.126, 4.130, Diagnostic Code 9411 (2019). 2. From August 12, 2015 to April 18, 2019, the criteria for entitlement to an evaluation of 70 percent, but no higher, for service- connected PTSD are met. 38 U.S.C. §§ 1155, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.126, 4.130, Diagnostic Code 9411 (2019). 3. The criteria for a disability rating in excess of 70 percent for PTSD after April 18, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 4. Prior to April 18, 2019 the criteria for entitlement to a TDIU have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.103, 3.340, 3.341(a), 4.16(a), 4.25 (2018). 5. From December 30, 2011 to May 1, 2014, the criteria for entitlement to SMC have been met. 38 U.S.C. §§ 1114(s) (2012); 38 C.F.R. § 3.350(i)(1) (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Air Force from August 1950 to May 1975. This case comes to the Board of Veteran’s Appeals (Board) on appeal from a May 2011 rating decision by the Department of Veteran’s Affairs (VA) Regional Office in Montgomery, Alabama. This issue was previously remanded in an April 2020 Board decision. During the pendency of the appeal, the regional office (RO) increased the disability rating for the Veteran’s PTSD to 50 percent, effective August 12, 2015 in a November 2015 rating decision. The RO then increased the rating once again to 70 percent effective April 18, 2019 in an August 2019 rating decision. Because the RO did not assign the maximum disability rating possible, the appeal remains in appellate status and is properly before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Veteran presented testimony before the undersigned Veterans Law Judge in a September 2017 Travel Board hearing. This issue was previously remanded in an April 2020 Board decision. 6. Entitlement to an evaluation of 70 percent and no higher prior to August 12, 2015 for PTSD is granted. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2019). The 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 (2019). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2019). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2019). 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 (2019). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). The Veteran was initially denied service connection for PTSD in a July 1997 rating decision. The Veteran then made another claim for service connection for PTSD and was denied in a February 2007 rating decision. The Veteran then made a claim for PTSD in February 2011. Service connection was granted at 30% in a May 2011 rating decision. The Veteran timely appealed the evaluation in a January 2012 rating decision, and as such the appeal period begins with the date of the claim, February 23, 2011. Psychiatric disorders are rated under the General Rating Formula for Mental Disorders which provides that mental disorders are to be rated under 38 C.F.R. § 4.130 as follows: A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent 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; memory loss for names of close relatives, own occupation, or name. Evaluation of a mental disorder requires consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. Evaluations will be assigned based on all evidence of record that bears on occupational and social impairment, rather than solely on an examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms and how those symptoms impact the veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, at 442 (2002). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. VA treatment records show that the Veteran was diagnosed with PTSD in December 2010. The Veteran saw his physician periodically for mental health treatment. Records from December 2010 through April 2012 show that the Veteran regularly complained of low frustration tolerance and difficulty sleeping. The Veteran denied suicidal or homicidal ideation. His mood was consistently documented as dysphoric and his speech restricted. The Veteran reported that he avoided crowds and was becoming more isolated. In June 2011 records, the Veteran said he went on vacation and spent the whole time in the hotel room in order to avoid people. In July 2011 records, the Veteran stated that most days he could not manage at work so he would often call in sick. The Veteran also found that he could not control his outbursts of anger. The Veteran stated in the April 2012 VA records that he had thoughts of harming himself. An April 2011 VA examination diagnosed PTSD. The Veteran’s main symptoms were his irritability and sleep disturbance. The Veteran was employed full time as a truck driver for the Anniston Army base and reported that he would intermittently call in sick to work because his low frustration tolerance caused friction with his coworkers. The VA examiner found that there was an occasional decrease in work efficiency due to the Veteran’s irritability. Otherwise, the examiner found that the Veteran was oriented as to person, time, and place, had good hygiene and spoke coherently. The Veteran denied ritualistic behaviors, panic attacks, suicidal ideation, and hallucinations. He reported good family relationships, though his marriage suffered occasionally due to his irritability. The Veteran stated that he had no friends or hobbies, although the VA examiner noted that the Veteran had limited social relationships prior to his service. The Veteran’s mood was noted as dysphoric and his affect was constricted. His remote and recent memory were normal. In November 2011 the Veteran’s treating physician submitted a statement that the Veteran was reportedly having marked difficulty functioning due to his PTSD symptoms. The Veteran’s wife also submitted a November 2011 statement in which she described the Veteran’s irritability, inability to socialize with others and restless sleeping habits. VA treatment records from March 2009 to May 2012 show that the Veteran had incidents of outbursts of anger, including one incident in which the Veteran shot at his wife and daughter. There was no date indicating exactly when the incident occurred, but it did prompt the Veteran to get rid of his firearms. The Veteran continued to report flashbacks and nightmares about his time in service. In April 2012 the Veteran indicated that he had contemplated harming himself but stated that he neither had a plan or the means to do so and reiterated that he did not have suicidal ideation. The Veteran continued to report increased irritability throughout this period. Medical treatment records from May 2012 to September 2014 continued to show that the Veteran complained of irritability, poor sleep quality and social isolation. The Veteran’s mood was noted to be anxious and his affect was noted as mood congruent. The Veteran continued to dress appropriately, was well oriented, and the examiner found that the Veteran had good recent and remote memory. The Veteran continued to deny suicidal and harmful ideation. The Veteran was still employed throughout this period, with plans to retire. The Board finds that an increased evaluation to 70 percent for this period is warranted. Despite the examiner in the April 2011 VA examination finding that the Veteran only experienced occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks, it is clear from medical records that the Veteran finds himself too debilitated to go to work on most days. The Veteran stated in both the April 2011 VA examination and July 2011 medical records that he often called in sick to work to avoid his coworkers. The Veteran also exhibited impaired impulse control, with instances of violence. His low frustration tolerance and unprovoked irritability consistently caused friction with his coworkers. The Veteran stated in July 2011 treatment records that he could not control his outbursts of anger. Treatment records also indicated that at some point the Veteran had an angry outburst that resulted in him threatening his wife and daughter with a firearm. The Veteran had also had several thoughts of harming himself throughout the appellate period. The Veteran also demonstrated an inability to establish and maintain effective relationships. Though the examiner in the April 2011 VA examination noted that the Veteran had few relationships prior to service it is clear that the Veteran’s isolative tendencies increased throughout this period. The Veteran could not leave his hotel room while on vacation for fear of interacting with others, according to June 2011 treatment records. The Veteran’s wife’s November 2011 statement affirmed the Veteran’s increasing inability to socialize with others as well as the strain on their marriage due to his irritability. Notably, suicidal ideation may cause occupational and social impairment in most areas. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017) (stating the language of 38 C.F.R. § 4.130 “indicates that the presence of suicidal ideation alone, that is, a veteran’s thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment in most areas.”). As such, the Board finds that an increased evaluation to 70 percent is warranted prior to August 12, 2015. A 100 percent evaluation is not warranted for this time period, however, as there is not total social and occupational impairment. Although the Veteran reported increasing social isolation and strained relationships, there was not total impairment as the Veteran maintained some relationships. The Veteran continued to work on his marriage and continued to endorse a good relationship with family members. Furthermore, the Veteran continued to be employed despite some altercations with coworkers. Despite missing work often and having friction with coworkers the Veteran continued to hold a job as a truck driver. The Veteran also did not report disorientation to time or place, or memory loss for names of close relatives, own occupation, or name. The Veteran continued to maintain proper hygiene and live independently. The Veteran’s symptoms as noted above were not of the duration, severity, or frequency, that caused total social and occupational impairment. 7. Entitlement to an evaluation of 70 percent and no higher from August 12, 2015 to April 18, 2019 for PTSD is granted. In October 2015, the Veteran had a VA examination. The Veteran reported an increase in depressive symptoms and was diagnosed with adjustment disorder which overlapped in symptomology with the Veteran’s diagnosed PTSD. The VA examiner found that the Veteran experienced occupational and social impairment with reduced reliability and productivity as a result of his symptoms. The Veteran’s wife referred to their marriage as “great,” although with occasional issues due to the Veteran’s irritability. The Veteran reported seeing his son and grandchild every other day, although he stated that he had grown more distant from his son as they no longer went fishing together due to the similarities between his fishing spot and the areas where he was stationed in the military. The Veteran denied any social contact or enjoyable activities. He described increasing verbal altercations with his coworkers and admitted to tardiness and absences from work because he did not feel like interacting with people. The Veteran stated that he was depressed, anxious and beginning to have mild memory loss that mostly effected his recent memory. He was cleanly and appropriately dressed, his speech was normal and goal-oriented, and he was well-oriented. When asked about suicidal ideation the Veteran stated that while he may have thought about it in the past, it was no longer an active intent. It was noted that the Veteran did not have any overt paranoid ideations, though the Veteran reported that he would “see things” that his wife could not see when he was checking outside the windows. In August 2015, the Veteran’s wife submitted a lay statement in which she reported that the Veteran’s PTSD symptoms had worsened. She stated that the Veteran was more aggressive and that he could not handle loud noises or crowds. The Veteran did not like being around too many people, including family members. She stated that he had difficulty sleeping due to his medication and that it caused him to hallucinate. The Veteran often kicked or punched in his sleep and did not remember doing so the following morning. The Veteran underwent another VA examination in April 2017. He retired from full-time employment in March of 2017. He reported verbal altercations with coworkers with the most recent incident being in 2015, being reprimanded by supervisors due to periodic absences, and a lack of motivation to perform job duties. The VA examiner found that the Veteran experienced occupational and social impairment with reduced reliability and productivity as a result of his symptoms. The Veteran’s wife stated that their marriage was “great,” although marital conflict was noted in the Veteran’s mental health notes, and the Veteran reported that he saw his son and granddaughter daily. The Veteran was cleanly dressed, and his thought processes were logical, and goal directed. The Veteran reported that his memory was worsening, as he often misplaced items or could not recall conversations. He endorsed an incident of suicidal ideation but denied any other plan or intent. He denied panic attacks, hallucinations or delusions. The Veteran testified at a hearing in September 2017 and reported that he could no longer work due to the side effects of his medication making it difficult for him to drive. The Veteran also stated that he often thought his wife would be better off if he were dead. The Veteran’s wife stated at the hearing that the Veteran was constantly patrolling the house at night and seeing things that are not there and the Veteran stated that he did not remember doing such things or seeing anything. The Veteran voiced that his wife was often anxious with him being around family members as she did not know if he would dissociate and act out violently. In April of 2018 the Veteran’s psychiatrist and support social worker provided a letter in which they stated that the Veteran had endorsed low frustration tolerance and memory loss. In October 2018, the Veteran’s treating physician submitted a letter in which he endorsed the Veteran’s symptoms of low frustration tolerance, poor memory, anxiety, poor sleep, and hypervigilance. VA treatment records from November 2014 to March 2019 showed that the Veteran was always appropriately dressed and well oriented to time, place and person. The Veteran denied suicidal ideation. His speech was noted as normal and his thought processes were goal oriented. The Veteran’s mood vacillated between dysphoric, irritable, or mildly anxious during the sessions with his affect being mood congruent. The Veteran continued to report poor sleep quality, increased isolation, worsening depression, and lack of motivation. The Veteran reported losing interest in his job in February 2016 and also reported issues in his marriage in May 2016. The Board finds that the Veteran is entitled to an increased evaluation of 70 percent for this period. Though the examiners in both the October 2015 VA examination and April 2017 examinations found that the Veteran experienced occupational and social impairment with reduced reliability and productivity, it is clear from the Veteran’s multiple instances of tardiness and calling out sick that his mental health condition more significantly inhibited his ability to work. In the April 2017 VA examination the Veteran reported friction with coworkers, being reprimanded by supervisors for continuous absences, and lack of motivation for the job. It is also evident that the Veteran exhibited impaired impulse control. There were multiple instances of verbal altercations with coworkers and the Veteran also stated in the September 2017 hearing that his wife would fear that he would hurt his grandchildren while in one of his dissociative episodes. The Veteran retired from the Anniston Army Depot in 2017 and attempted to work as a school bus driver but also found himself getting into conflicts with his coworkers and the children. This indicates that the Veteran continued to have difficulty adapting to stressful circumstance in the work setting due to his lack of impulse control. The Veteran also admitted to having had suicidal thoughts in the October 2015 and April 2017 VA examinations as well as in the September 2017 hearing. The October 2015 VA examination and May 2016 treatment records indicated that the Veteran was having trouble in his relationships with his wife and son. Other treatment records show that the Veteran continued to become more isolated and have significant difficulty creating or maintaining effective relationships. Notably, suicidal ideation may cause occupational and social impairment in most areas. Bankhead, 29 Vet. App. at 19. As such, the Board finds that the Veteran is entitled to a 70 percent evaluation for this period. A 100 percent evaluation is not warranted for this time period, however, as there is not total social and occupational impairment. Although the Veteran reported increasing social isolation and strained relationships with his wife and son, there was not total impairment as the Veteran still maintained these relationships. The Veteran continued to work on his marriage and there were times when the Veteran’s wife reported that their relationship was “great.” The October 2015 and April 2017 VA examinations also noted that the Veteran saw his son and grandchild every other day or daily. Furthermore, the Veteran continued to be employed at Anniston Army Depot until 2017 when he chose to retire. The Veteran reported some perceptual disturbances such as seeing things outside the window, but the Veteran did not report or show disorientation to time or place, or memory loss for names of close relatives, own occupation, or name. There was memory loss, but not to that extent. The Veteran’s symptoms as noted above were not of the duration, severity, or frequency, that caused total social and occupational impairment. 8. Entitlement to an evaluation in excess of 70 percent after April 18, 2019 is denied. In April 2019 the Veteran underwent another VA examination. The Veteran was diagnosed with PTSD and with Unspecified Depressive Disorder. The examiner found that the Veteran suffered occupational and social impairment with deficiencies in most areas such as work, school and family relations. The examiner noted that the Veteran’s marriage was difficult as the Veteran did not want to go anywhere with his wife and he was often short and aggressive towards her. The Veteran had struck his wife previously. The Veteran had a similarly strained relationship with his son and tended to avoid meeting with him. He was not close with his grandchildren and had no friends and did not belong to any social groups or Veteran groups. The Veteran stopped working at the Army Depot in 2017, and afterwards he attempted to continue working as a school bus driver but found himself getting into conflicts with his coworkers and the children. The Veteran exhibited depressed mood, anxiety, and suspiciousness. He had chronic sleep impairment, mild memory loss, and a flattened affect. The Veteran experienced disturbances in mood and motivation, inability to establish effective relationships, and impaired impulse control. The examiner noted during the examination that the Veteran was well-dressed, clean and hygienic. The Veteran’s concentration was within normal range and though he was irritable, he was cooperative. The Veteran stated that he had suicidal ideation, but no current intent and he denied any homicidal ideation. Medical treatment records from April 2019 to August 2019 show that the Veteran continued to report a lack of motivation, low frustration tolerance, and isolative tendencies. The Veteran continued to be appropriately dressed, oriented to time, place, person, and situation and consistently denied suicidal ideation. The Veteran’s treating physician provided an August 2019 letter in which he reported that the Veteran experienced poor sleep, anxiety, depression, and intolerance of small and large groups. The Veteran exhibited cue avoidance, social isolation, flashbacks, hypervigilance, unprovoked irritability, panic, and difficulty adapting to stressful circumstances. The physician confirmed that these symptoms made it difficult for the Veteran to function in daily life. The Veteran underwent another VA examination in September 2019. The examiner noted that the Veteran experienced occupational and social impairment with reduced reliability and productivity. The examiner noted that the Veteran had been married twice and that the current marriage was difficult due to the Veteran’s irritability. The Veteran continued to have contact with all but four of his adult children. The Veteran also had occasional contact with his siblings. He also reiterated that he did not see friends often. The Veteran presented as casually dressed and well groomed. Speech was within normal limits and the Veteran was well oriented. Abstract thinking was within normal limits and thought processes were unremarkable. The Veteran denied any current suicidal ideation but endorsed sleep disturbances and increased anxiety and irritability. The Board finds that the Veteran is not entitled to a 100 percent rating after April 18, 2019 as the evidence does not indicate that the Veteran experienced total social impairment. The Veteran remains married despite marriage difficulties. The Veteran confirmed in the medical treatment records that he spent nearly all his time around his wife. While the Veteran reported that he did not have any friendships and did not participate in social groups, the Veteran continued to have contact with most of his adult children as well as occasional contact with his surviving siblings. The Veteran had not reported having persistent delusions and did not exhibit any grossly inappropriate behavior. The Veteran consistently denied homicidal ideation and while he stated in the VA examinations that he had suicidal ideation he did not have any plan or intent. The examiners in both the April 2019 and September 2019 examinations noted that the Veteran was appropriately dressed and groomed and well oriented. The Veteran did exhibit memory loss but has not reported it to the extent of forgetting family members, occupation, or self. As the Veteran is not experiencing total impairment of social relationships and does not exhibit many of the characteristics within the criteria for a 100 percent evaluation under the applicable diagnostic code, an increased evaluation is not warranted. 9. Entitlement to service connection for TDIU prior to April 18, 2019 is granted. VA will grant TDIU when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU is granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. 38 C.F.R. § 4.16(a). If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. 38 C.F.R. §§ 3.340, 3.341, 4.16. The central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the veteran’s background including his employment and educational history. 38 C.F.R. §§ 3.321(b), 4.16(b). The Board does not have the authority to assign an extraschedular TDIU rating in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rather, the issue must be referred to the Director of Compensation Service for such assessment in the first instance. Kuppamala v. McDonald, 27 Vet. App. 447, 457 (2015). Thereafter, the Board has jurisdiction to review the entirety of the Director’s decision denying or granting an extraschedular rating and is authorized to assign an extraschedular rating when appropriate. Kuppamala, 27 Vet. App. at 457. For VA purposes, the term unemployability is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91, 57 Fed. Reg. 2,317 (Jan. 21, 1992). Consideration may be given to the veteran’s education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, 4 Vet. App. at 363. The ability to work sporadically or obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). Due to the determinations made above, service connection is in effect for the following disabilities: (1) PTSD, 70 percent, effective February 23, 2011; (2) prostate cancer, 100 percent, effective December 30, 2011, and 40 percent, effective May 1, 2014; (3) benign growth on the right, seventh rib, zero percent, effective May 28, 1975; (4) left inguinal hernia, post-op, zero percent, effective May 28, 1975; and (5) erectile dysfunction, secondary to prostate cancer, zero percent, effective August 21, 2015. The RO granted TDIU, effective April 19, 2019. The Board will thus consider the TDIU claim prior to that date. Beginning on February 23, 2011, the Veteran’s PTSD is now rated at 70 percent. As there were several other service-connected disabilities, and his PTSD was rated at least 40 percent, the schedular criteria are met as of that date. 38 C.F.R. § 4.16(a). Notably, however, the Veteran was employed until March 2, 2017, when he retired. Prior to that date, he remained employed on a full-time basis at Anniston Army Depot and there is no evidence that this was not substantially gainful employment. Accordingly, TDIU prior to that date is not warranted. However, prior to April 18, 2019, when considering the record as a whole and resolving reasonable doubt in the Veteran’s favor, the Board finds that Veteran’s service-connected PTSD and prostate cancer rendered him unable to secure and follow a substantially gainful occupation during the appeal period. The record indicates that the Veteran worked at the Anniston Army Depot for 16 years as a truck driver. He was able to finish high school but lost interest in education and never completed community college. In the April 2017 VA examination, the Veteran stated that he had had difficulties while working at the Army Depot. He reported being isolated from coworkers and having frequent arguments with them. The Veteran stated that he had been reprimanded by supervisors for leaving work early or calling out from work due to his PTSD symptoms. He stated that his absences from work were becoming more frequent as he prepared for retirement. The examiner found that the Veteran was likely to have difficulties with employment due to his mental health condition. The examiner noted that the Veteran would likely have problems interacting with coworkers and supervisors due to his irritability, reduced work performance due to concentration and memory issues, difficulty tolerating stress, problems with anxiety and paranoia, and fatigue due to lack of sleep. The Veteran also stated that the physical consequences of his prostate cancer would also hinder his ability to have substantially gainful employment. He stated that he had persistent urinary incontinence and diarrhea and that it would likely keep him from concentrating on his work. He stated that he had had an embarrassing incident at work due to these conditions. In a September 2017 hearing the Veteran also stated that his medications made him tired and rendered him unable to drive. As such, he could not perform his job duties. In the April 2019 VA examination, the Veteran stated that he attempted to get another job after retiring in compliance with his therapist’s advice. The Veteran tried to work as a school bus driver but found that he got into conflict with coworkers and the children. The evidence reflects that the manifestations of the Veteran’s service-connected PTSD and prostate cancer, when taken together, rendered him incapable of obtaining or maintaining substantially gainful employment, based on the Veteran’s educational and past work experience. The Veteran is unable to drive or stay in one place for a long period due to his incontinence. The symptoms of his PTSD also made it extremely difficult for him to interact with others. Consequently, the majority of the evidence of record demonstrates that the Veteran was not able to sustain such employment due to the combination of his service-connected disabilities. Accordingly, TDIU is warranted prior to April 18, 2019. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 10. Entitlement to SMC A veteran is presumed to be seeking the maximum benefit allowed by law or regulation, and such a claim remains in controversy, even if partially granted, where less than the maximum benefit available is awarded. A.B. v. Brown, 6 Vet. App. 35, 38 (1993). Moreover, VA has a duty to fully and sympathetically develop a veteran's claim to its optimum, which includes determining all potential claims raised by the evidence and applying all relevant laws and regulations. Moody v. Principi, 360 F.3d 1306, 1310 (Fed. Cir. 2004). Relevant to this appeal, a claim for increased disability compensation may include the "inferred issue" of entitlement to SMC even where the veteran has not expressly placed entitlement to SMC at issue. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991); Buie v. Shinseki, 24 Vet. App. 242 (2010) (requiring VA to assess all of the claimant's disabilities to determine whether entitlement to SMC under 38 U.S.C. § 1114(s) is established whenever a veteran with a total disability rating is subsequently awarded service connection for any additional disability or disabilities even in the absence of an express claim for SMC). Special monthly compensation at the housebound rate is payable where a veteran has a single service-connected disability rated as 100 percent and: (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s) (2012); 38 C.F.R. § 3.350(i) (2018). Initially, the Board grants SMC at the housebound rate from December 30, 2011 to May 1, 2014. For this period, the Veteran was in receipt of a 70 percent evaluation for service-connected PTSD and a 100 percent evaluation for service-connected prostate cancer. Thus, the Veteran has a total rating and separate disabilities rated as 60 percent or more during this time period. Entitlement to SMC is warranted. Next, the Board finds that SMC is not for consideration as of the date of the grant of TDIU. The TDIU is based on the only two service-connected disabilities that are evaluated in excess of zero percent. Thus, the criteria are not for application. 38 U.S.C. § 1114; 38 C.F.R. § 3.350(i); Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ashley Ki The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.