Citation Nr: 21000298 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 15-45 590 DATE: January 5, 2021 ORDER Entitlement to a 50 percent, but no higher, rating prior to July 22, 2019 for posttraumatic stress disorder (PTSD) is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a 70 percent, but no higher, rating from July 22, 2019 for PTSD is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted, subject to the regulations governing the payment of monetary awards. FINDINGS OF FACT 1. Prior to July 22, 2019, the Veteran’s PTSD was manifested by symptoms causing occupational and social impairment with reduced reliability and productivity. 2. From July 22, 2019, the Veteran’s PTSD has been manifested by occupational and social impairment with deficiencies in most areas. 3. The Veteran’s service-connected disabilities preclude him from securing or following substantially gainful employment consistent with his education and industrial background.  CONCLUSIONS OF LAW 1. Prior to July 22, 2019, the criteria for a 50 percent, but no higher, rating for PTSD are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2020). 2. From July 22, 2019, the criteria for a 70 percent, but no higher, rating for PTSD are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2020). 3. The criteria for entitlement to TDIU are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 4.18, 4.19 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Marine Corps from March 1952 to March 1972. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a January 2019 rating decision, the Agency of Original Jurisdiction (AOJ) increased the Veteran’s rating for his service-connected PTSD from 30 percent to 50 percent, effective July 7, 2017. The Veteran testified before the Board at a hearing in January 2018. A transcript of the hearing is of record. Subsequently, the Board remanded the case in April 2018, April 2019, and December 2019 for further development.   Increased Rating – PTSD The Veteran and his attorney contend the Veteran is entitled to increased ratings for his service-connected PTSD. See Third Party Correspondence, dated April 15, 2020. The AOJ has assigned the Veteran’s PTSD a 30 percent rating prior to July 7, 2017 and a 50 percent rating thereafter, pursuant to the criteria of Diagnostic Code 9411, which is included under the General Rating Formula for Rating Mental Disorders. 38 C.F.R. § 4.130. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 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. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has 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). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under the General Rating Formula for Rating Mental Disorders, a 30 percent rating is assigned for occupational and social impairment with decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9440. A 50 percent disability rating is assigned when there is 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, for example, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned when there is objective evidence demonstrating 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; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: 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 and place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms in the General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, “a [V]eteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Furthermore, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. Prior to July 22, 2019 Based on a review of the relevant evidence and the applicable law and regulations, it is the Board’s conclusion that a 50 percent, but no higher, rating for the Veteran’s PTSD is warranted prior to July 22, 2019. During this period, the Veteran attended VA examinations in September 2014 and January 2019 for an evaluation of his PTSD. At a September 2014 VA examination for an evaluation of the Veteran’s PTSD, the VA examiner diagnosed the Veteran with PTSD. The VA examiner indicated the level of occupational and social impairment was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner noted that the symptoms that applied to the Veteran’s diagnosis were depressed mood and anxiety. The Veteran reported at the examination that he had a good relationship with his four adult children. Furthermore, he reported that he was working as a mortician/funeral director/embalmer. He denied having performance problems, ever being fired from a job, or having difficulties with supervisors or coworkers. The Veteran attended an additional VA examination in January 2019 for an evaluation of his PTSD. The VA examiner diagnosed the Veteran with PTSD. The VA examiner indicated the level of occupational and social impairment was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner noted that the symptoms that applied to the Veteran’s diagnosis were anxiety and chronic sleep impairment. During the mental status examination, the Veteran was alert and oriented, he had a normal affect, his thoughts were clear and connected, and he made good eye contact. The Veteran reported that he sees images of his time in combat sometimes, but the Veteran denied any other significant hallucinations, delusions, or psychosis. The Veteran reported at the examination that he had a good relationship with his spouse and children. He reported having 10 friends that he talked to 2 times a week. He reported that he played golf as much as he could, was a part of the Veterans of Foreign Wars and Disabled American Veterans and attended church every Sunday. Furthermore, he reported that he retired around 2000, but that he still does about three hours of funeral activities a week. In addition, he reported attending a Veteran Support Group two times a month, and he reported taking no psychiatric medications. In addition to the VA examinations addressed above, the Veteran has received VA psychiatric treatment throughout this period. A thorough review of the VA psychiatric treatment notes reveal that at no point during this period did the Veteran present with symptoms of suicidal ideation; obsessional rituals which interfered with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; neglect of personal appearance and hygiene; or difficulty in adapting to stressful circumstances, including work or a work-like setting. An April 2013 VA treatment note reflects that the Veteran reported feeling cut off or detached from others very often, indicating that it has happened three or four times in the two weeks before the appointment. He reported that his ability to experience a whole range of emotions was impaired and had happened three or four times in the two weeks before the appointment. He stated that he had been continuously irritable or had experienced outbursts of anger at least twice in the last two weeks. He reported being constantly overly alert and that he had been easily startled two or three times in the last two weeks. A July 2013 VA treatment note reflects that the Veteran reported having intermittent marital problems, and he reported that they saw a counselor together or separately. The Veteran reported having arguments with his spouse at a July 2017 VA appointment. He also endorsed anxiety, hypervigilance, irritability, avoidance of crowds and restaurants, avoidance of sleep, and feelings of sadness. He reported having close relationships with his four children. He indicated that he had been married three times and reported that he had physical altercations with his second wife and had been arrested for domestic violence. He indicated that his third wife did not understand him, or his issues related to PTSD. During this appointment, the mental status examination reflected that he was alert and attentive, oriented to time, location, and situation and had normal rate and rhythm of speech and clear and coherent speech. His affect was congruent with his mood, which was dysphoric. His thought process was normal and coherent, and he had no unusual thought content. His insight was good and judgment within normal limits. There was no obvious impairment of cognition. He denied suicidal ideation. In a September 2017 VA treatment record, the Veteran endorsed having continued nightmares, anxiety, irritability, avoidance of sleep, and sadness. He was dressed appropriately and exhibited adequate personal hygiene. He was alert and oriented and had clear, coherent, and linear speech. His mood was dysphoric with congruent affect and he displayed adequate insight, logic, and judgment and his thought processes were intact. He denied homicidal and suicidal ideation and did not endorse audio or visual hallucinations. The Veteran reported at July 2014 and January 2019 VA examinations that he had a good relationship with his four adult children. He also reported at the January 2019 examination that he has 10 friends that he talks to two times a week, and he described his marriage as “good” at the examination. At the January 2018 Board hearing, the Veteran testified to getting frustrated and hostile towards others when trying to explain something that the other people are not understanding. He reported getting into altercations with clients at his funeral home and sometimes needing to excuse himself to allow another funeral director to take over. He reported having flashbacks about three to five times a week and having sleep impairment. His spouse testified that sometimes he gets mad at her and he will just stop talking. She reported that he has injured himself during bad dreams and that she has observed him having flashbacks when she has had to tell him to pull himself together. He reported that there was domestic violence during his second marriage. He indicated there had been similar situations during his third marriage, but that it had basically been a good marriage. He indicated that at times his spouse will say things and he will explode and become somewhat hostile. He stated that he would sometimes leave the house or take other measures to try to get himself together in order to avoid confrontation, particularly physical confrontation. Based on the evidence of record, the Board concludes that the frequency, duration, and severity of the Veteran’s symptoms prior to July 22, 2019 caused occupational and social impairment with reduced reliability and productivity, and a 50 percent rating is warranted. For example, a September 2015 VA treatment note reflects that the Veteran reported having a depressed mood and decreased motivation and interest. The mental status examination at the September 2015 appointment revealed the Veteran had an anxious and depressed mood and his affect was congruent with his mood. In addition, the VA treatment notes consistently reflect irritability without periods of violence during the period as is noted above. This evidence and the other evidence of record reflects that the frequency, duration, and severity of the Veteran’s symptoms of decreased motivation and mood, along with the evidence of irritability, most nearly approximated a rating of 50 percent prior to July 22, 2019. The Board also concludes that a preponderance of the evidence is against a finding that the frequency, duration, and severity of the Veteran’s psychiatric symptoms resulted in occupational and social impairment with deficiencies in most areas or total occupational and social impairment throughout the appeal period. The Board acknowledges that at an August 2011 VA examination, prior to the period on appeal, the Veteran reported having anger outbursts, irritability, that he gets out of control, and that he had a fight earlier in the year with a man that was making disparaging comments. However, the evidence of record illustrates that the report of the fight at the August 2011 VA examination was prior to the relevant period before the Board as the Veteran filed his claim for an increased rating in September 2013 and the period on appeal goes back to September 2012. Furthermore, the Board acknowledges that the Veteran reported at his January 2018 Board hearing that he had altercations at work, confrontations with people outside of work, and a history of domestic violence in his second marriage. See Board Hearing Transcript, dated January 5, 2018, pages 5-7. In addition, the Board acknowledges the April 2020 Third Party Correspondence in which the Veteran’s attorney reported that the Veteran has been married three times, there has been a history of domestic violence, and that the Veteran has difficulty in public. The Board also acknowledges the Veteran’s spouse’s testimony at the January 2018 Board hearing that the Veteran gets mad when they talk. See Board Hearing Transcript, dated January 5, 2018, page 6. Lastly, the Board acknowledges that the Veteran’s spouse reported at the January 2019 VA examination that about three years prior to the examination, the Veteran grabbed her and hurt her shoulder. However, the Veteran has also testified that he took measures to avoid physical confrontations by leaving intensifying situations, including by leaving the house during arguments with his spouse, or having another funeral director take over if he felt an argument was escalating at work. Although the evidence reflects periods of impaired impulse control, the Board finds that the frequency, severity, and duration of these symptoms have not resulted in deficiencies in most areas, given that the Veteran has reported taking protective measures of getting out of situations where he feels that things could escalate to where he will not be able to control himself. The Board does not minimize the report of violence approximately three years prior to the January 2019 VA examination; however, in considering the frequency, duration, and severity of his impaired impulse control, it was not shown to result in deficiencies in most areas prior to July 22, 2019, given the evidence that he usually employed protective measures to keep his impulse control in check. Although the record indicates the Veteran has a difficulty in establishing and maintaining effective relationships, the record does not reflect that the frequency, duration, and severity of the symptom more nearly approximates an inability to establish and maintain effective relationships. This is exemplified by the Veteran’s reports of having good relationships with his four adult children and his report at the January 2019 VA examination that he had 10 friends that he talks to two times a week. The Board notes that the Veteran was noted to have spatial disorientation at an October 2017 VA appointment. However, the VA examinations during this period are silent for spatial disorientation. Furthermore, aside from the October 2017 VA treatment note, the VA treatment notes during this period are otherwise silent for spatial disorientation. Therefore, the frequency, duration, and severity of this symptom was not shown to result in deficiencies in most areas or in total occupational and social impairment. The Board also notes the Veteran reported in August 2015 that he ducks and covers when a helicopter is overhead, and the Board notes that the Veteran and his spouse reported that the Veteran has nightmares. Furthermore, the Veteran reported at the January 2019 VA examination that he sees images of his time in combat sometimes, but the Veteran denied any other significant hallucinations, delusions, or psychosis. VA mental status examinations are silent for persistent delusions or hallucinations. Thus, the evidence of record does not support a finding of persistent delusions or hallucinations to support a higher 100 percent rating. The medical and lay evidence of record during this period illustrates that the frequency, duration, and severity of the Veteran’s symptoms prior to July 22, 2019 are not reflective of occupational and social impairment with deficiencies in most areas. The record does not reflect symptoms, such 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; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; an inability to establish and maintain effective relationships; or any other similar symptoms that were of such frequency, duration, and severity to result in occupational and social impairment with deficiencies in most areas. As such, the Board finds that a 50 percent rating, but no higher, is warranted prior to July 22, 2019.   From July 22, 2019 Based on a review of the relevant evidence and the applicable law and regulations, it is the Board’s conclusion that a 70 percent, but no higher, rating for the Veteran’s PTSD is warranted beginning July 22, 2019. A VA mental health assessment dated July 22, 2019 reflects that the Veteran reported having problems with depression for about two weeks. Furthermore, the Veteran reported at an October 2019 VA appointment that he was an active person until July 2019, which is when his symptoms came down on him all of a sudden. The Veteran’s spouse reported at the same October 2019 appointment that the Veteran’s memory problems worsened since July 2019. In addition, a November 2019 VA treatment note reflects that the Veteran reported ongoing symptoms of depression, such as loss of interest, loss of pleasure, poor appetite, poor motivation, and poor energy level. In addition to the evidence above, the Veteran attended a VA examination in February 2020 for an evaluation of his PTSD where the VA examiner diagnosed the Veteran with PTSD and mild neurocognitive disorder. The examiner noted that the symptoms attributable to the PTSD diagnosis were intrusion and avoidance. The examiner noted that the symptoms attributable to the Veteran’s mild neurocognitive disorder were mild memory loss and difficulty in understanding complex commands. The symptoms attributable to both diagnoses were depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and impaired impulse control. The VA examiner indicated the level of occupational and social impairment was occupational and social impairment with reduced reliability and productivity. During the mental status examination, the Veteran was fully oriented, he was appropriately dressed, his mood and affect were normal, he denied suicidal ideation, and he denied any psychotic symptoms. The Veteran acknowledged some memory problems in the preceding three to four months. The examiner noted that the Veteran seemed to have difficulty answering some questions in that he needed to take more time to answer some questions and he occasionally gave vague answers. The examiner noted that the Veteran had difficulty on a working memory task. The Veteran reported at the examination that he and his spouse occasionally bump heads. He reported having a good relationship with his children. He reported having quite a few friends in the local area, and he reported going to church every Sunday. He reported that he does not golf anymore after he injured his hand about five months prior to the examination. He stated that he hit a wall and fractured his hand during a time when he was angry. Furthermore, he reported that he has flashbacks that are triggered unexpectedly, and that they are sometimes triggered by the landing patterns of the planes near his home. He reported anger, characterized as saying things he does not mean and lashing out at his spouse. He reported that his appetite is low, and that he frequently does not eat unless being prompted to do so. The Veteran’s spouse reported concerns about the Veteran’s memory at the examination. The Board acknowledges that the February 2020 VA examiner indicated that the Veteran’s PTSD symptoms may be at least in part related to a nonservice-connected condition, in particular the symptoms of mild memory loss and difficulty in understanding complex commands; however, the examiner also indicated that there could be an association between the Veteran’s PTSD and neurocognitive disorder. The February 2020 VA examiner also attributed the symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and impaired impulse to both the PTSD and the mild neurocognitive disorder diagnoses. As such, the Board will attribute all of the symptoms described to the Veteran’s service-connected PTSD. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Based on the evidence of record, the Board concludes that the frequency, duration, and severity of the Veteran’s symptoms from July 22, 2019 have caused occupational and social impairment with deficiencies in most areas, and a 70 percent rating is warranted. In reaching this conclusion, the Board acknowledges the Veteran’s attorney’s contentions in the April 2020 Third Party Correspondence that the Veteran’s symptoms most nearly approximate a 70 percent rating based in part on the February 2020 VA examination reflecting the Veteran has impaired impulse control and neurocognitive symptoms. The Veteran’s symptoms do not more nearly approximate a rating of 100 percent, as they are not of such a severity, frequency or duration, to result in total occupational and social impairment. The Board notes the Veteran’s memory issues, as is evident by VA treatment notes since July 2019, the February 2020 VA examination, and the lay reports of the Veteran and his spouse; however, the medical and lay evidence of record does not illustrate that the Veteran has memory loss for names of close relatives, his occupation, or his own name. Thus, this symptom alone is not of such frequency, duration, and severity to result in total occupational and social impairment. Although the Veteran reported that he and his spouse occasionally bump heads, he also reported he continued to have a good relationship with his children and that he had quite a few friends in the local area. Therefore, his symptoms are not reflective of total social impairment. Furthermore, there is no evidence of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting others, intermittent inability to perform activities of daily living, or disorientation to time or place; or other symptoms of such frequency, duration, and severity to reflect total occupational and social impairment. As such, notwithstanding the memory loss, the evidence since July 22, 2019 most nearly approximates a 70 percent, but no higher, rating. There are no other symptoms, either listed in the rating criteria or otherwise reflected in the record, throughout the appeal period of such frequency, duration, and severity that are reflective total occupational and social impairment. In summary, the Board finds that the evidence most nearly approximates an assignment of a 70 percent, but no higher, rating for PTSD beginning July 22, 2019.   TDIU The Veteran and his attorney contend the Veteran is entitled to TDIU due to his service-connected disabilities. See Third Party Correspondence, dated April 15, 2020. VA will grant TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from obtaining or maintaining “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). The established policy of VA reflects that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. Factors such as employment history and educational and vocational attainments are to be considered. Id. For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The Court recently held that “substantially gainful occupation” contains both economic and noneconomic components. Ray v. Wilkie, 31 Vet. App. 58 (2019). The economic component “simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The non-economic component requires consideration of the Veteran’s history, education, skill, and training, and physical and mental ability to perform the activities required by an occupation. Further, the word “substantially” suggests an intent to impart flexibility into a determination of overall employability, as opposed to requiring the appellant to prove that he is 100 percent unemployable. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). 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). In this case, the Veteran has met the schedular requirements for a TDIU throughout the applicable appeal period as the Veteran’s combined rating for his service-connected disabilities has been at least 70 percent since the award of the 50 percent rating assigned herein for the Veteran’s PTSD. Furthermore, the Veteran’s rating of at least 50 percent for his PTSD throughout the appeal period meets the requirement of having at least one disability rated at 40 percent or more when there are two or more disabilities and sufficient additional disability to bring the combined rating to 70 percent or more. Thus, the schedular requirements for a TDIU rating are met throughout the appeal period. During this period, the Veteran was also service-connected for residual fragment wounds to the left and right heels, hallux valgus of the right and left feet, left and right foot hammer toes, left and right foot heel spurs, diabetes mellitus, tinnitus, bilateral hearing loss, residual fracture of the right thumb, tonsillectomy, and a bilateral hydrocele. The question remaining is whether the Veteran’s service-connected disabilities (alone) render him incapable of participating in a substantially gainful occupation. Here, the evidence of record reflects that the Veteran has not worked full-time during the appeal period. At his January 2018 Board hearing, the Veteran stated that he reduced his employment about five or six years prior to the Board hearing. At the time of the Board hearing, the Veteran indicated that he was making around $2,000 a year working at a funeral home. See Board Hearing Transcript, dated January 5, 2018, page 15. Such work would not be considered a substantially gainful occupation under VA policy. The Veteran also reported at his January 2018 Board hearing that a combination of his service-connected foot disabilities and PTSD caused him to reduce his employment as a funeral director. See Board Hearing Transcript, dated January 5, 2018, page 16. Relevant competent evidence of record helps inform the Board on the issue of unemployability. In his September 2017 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, the Veteran reported that his PTSD, bilateral foot, and bilateral heel conditions prevented him from securing or following any substantially gainful occupation. He reported that since 2001 he had been working at a funeral home and that his highest gross earnings during that time were $2,000 a year. He reported completing two years of college and having attended funeral director/mortuary school in the 1970s. He indicated that he could no longer perform the physical and mental duties of gainful activity. At the July 2014 VA examination, the Veteran reported that he continued to work as a mortician/funeral director. He denied having performance problems, ever being fired from a job, or having difficulty with supervisors or co-workers. At the January 2019 VA examination, the Veteran reported that he had retired around 2000 and indicated that he continued to do some funeral activities for about three hours a week for people he knows. The October 2016 hearing loss and tinnitus VA examination report reflects that the Veteran reported that his service-connected bilateral hearing loss prevented him from hearing at all according to his spouse, but the Veteran attributed that to the ringing in his ears. At the January 2018 hearing, the Veteran testified that as a funeral director he had to be very sensitive to families in a time of loss and that sometimes he would become more direct than he perhaps should have and his co-workers talked to him about these interactions. He also reported getting frustrated and hostile towards others when trying to explain something that the other people are not understanding. He reported getting into altercations with clients at his funeral home and sometimes needing to excuse himself to allow another funeral director to take over. He indicated that he started to eliminate direct contact with the families and in making funeral arrangements. He indicated that his feet also caused him trouble with working. He reported that he had discomfort in walking from pain and swelling, and that at times he would become immobile due to the pain. He stated that he could not handle a full time, 40-hour work week job due to the mental stress and his inability to walk and handle certain things. The March 2018 diabetes VA examination report reflects that the Veteran’s service-connected diabetes caused no functional impact. The January 2019 foot VA examination report reflects that the Veteran’s service-connected bilateral hallux valgus, bilateral hammer toes, and bilateral heel spur cause pain when walking for long periods. The February 2019 heel VA examination report reflects that the Veteran’s service-connected bilateral heel disabilities would impact the Veteran’s ability to perform jobs that require prolonged standing or walking. The February 2020 VA examination report for the Veteran’s PTSD reflects that the examiner concluded that the Veteran’s PTSD would cause occupational impairment with reduced reliability and productivity from symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, difficulty in understanding complex commands, disturbances of motivation and mood, and impaired impulse control. At the examination, the Veteran’s spouse reported that she had taken over doing more things for him, including paying bills. She indicated that he became frustrated, depressed, and anxious when he attempted to pay bills. There is no indication in the record, and the Veteran has not alleged, that his service-connected right thumb, tonsillectomy, or bilateral hydrocele disabilities cause any functional impairment. The Board acknowledges the Veteran’s statements at the January 2018 Board hearing that his service-connected PTSD and bilateral foot disabilities preclude him from working. Furthermore, the Board acknowledges the April 2020 Third Party Correspondence in which the Veteran’s attorney stated that the Veteran’s bilateral foot disabilities cause significant limitations in his abilities to perform physical activities due to problems with standing and walking. In addition, the Veteran’s attorney stated that the Veteran’s PTSD limits his ability to perform substantial gainful activity. In examining the evidence of record, the Board concludes that the evidence is at least in equipoise that the Veteran’s service-connected disabilities, in particular his PTSD and bilateral foot and heel disabilities, prevent him from obtaining and maintaining substantially gainful employment. In particular, the Board finds that the Veteran’s difficulty with interacting with clients and co-workers, including his periods of impaired impulse control, his recent memory and cognitive problems as reflected in July 2019 VA treatment records and at the February 2020 VA examination, and the pain and swelling in his feet that cause difficulty with walking and standing would preclude him from obtaining and maintaining substantially gainful employment that is consistent with his educational and occupational background. Therefore, when looking at the totality of the relevant factors, the Board finds that entitlement to TDIU is warranted. 38 C.F.R. § 4.16(a). M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Breitbach, Associate Counsel 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.