Citation Nr: 21000988 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 13-13 533 DATE: January 6, 2021 ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted, subject to the laws and regulations governing the award of monetary benefits. FINDINGS OF FACT 1. The Veteran does not have a current, valid diagnosis of PTSD or any other psychiatric disability other than primary alcohol and substance abuse disorders in remission. 2. Throughout the appeal period, the Veteran has had at least one service-connected disability rated 40 percent and a combined evaluation of 70 percent; and the evidence is at least in equipoise that the combined effects of the Veteran’s service-connected disabilities – namely coronary artery disease (CAD), right shoulder separation residuals, the lumbar spine disability, and the right knee disability – have rendered him unable to secure and follow substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for a psychiatric disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for an award of a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 4.1, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from November 1966 to November 1970, to include service in the Republic of Vietnam, for which he received the Purple Heart Medal. These matters come before the Board of Veterans’ Appeals (Board) on appeal from June 2010 and December 2013 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office. The Board previously remanded this appeal multiple times, most recently in February 2020. The Board finds that VA has substantially complied with that remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D’Aries v. Peake, 22 Vet. App. 97 (2008). The Board has thoroughly reviewed all the evidence in the Veteran’s VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for the Board’s decision, as well as to facilitate review by the Court. 38 U.S.C. § 7104(d)(1); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See id. Moreover, the Board will not repeat here in full pertinent regulations that the Agency of Original Jurisdiction (AOJ) previously provided in the Statement of the Case (SOC) or prior Supplemental Statements of the Case (SSOCs). 1. Service connection for psychiatric disability is denied. The Veteran seeks to establish service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). He claims that he has a current psychiatric disability that is related to active service. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). For service connection claims for PTSD in particular, the evidence must show: (1) medical evidence diagnosing the condition in accordance with the applicable edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence verifying that the claimed in-service stressor occurred. See 38 C.F.R. §§ 3.304(f), 4.125(a). A VA rule amended 38 C.F.R. § 4.125 to replace all references to the DSM-IV with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014); 80 Fed. Reg. 14,308 (Mar. 19, 2015) (final rule recognizing that the DSM-IV was rendered obsolete by the publication of the DSM-5 in May 2013). The Secretary specified that: the DSM-IV will apply to claims that were initially certified for appeal to the Board, CAVC, or the Federal Circuit prior to August 4, 2014; and the DSM-5 will apply to all applications for benefits received by VA or pending before the AOJ on or after August 4, 2014. Here, the DSM-V applies because this appeal initially was certified to the Board in October 2015. See October 2015 certification / transfer notice. The requirement of a current disability is satisfied when the claimant is shown to have the disability either at the time he files his claim for service connection, or during the pendency of that claim, even if the disability resolves prior to final adjudication. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When the record contains a recent diagnosis of disability prior to the filing of a claim for benefits based on that disability, the report of diagnosis is relevant evidence that must be addressed in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). In the absence of proof of a current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328, 1333 (1997). It is not categorically true that a formal diagnosis is required to satisfy the current disability element for all service connection claims. See Saunders v. Wilkie, 886 F.3d 1356 (holding that pain alone may constitute a current disability if it functionally impairs earning capacity). However, this Saunders principle is limited in service connection claims for mental disorders because the plain language of 38 C.F.R. § 4.130 requires a valid, current psychiatric diagnosis under the applicable version of the DSM. See Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 401, 404 (2020). Alcohol abuse and other forms of substance abuse are not disabilities for purposes of VA compensation. VA law and regulations preclude compensation for primary substance abuse disabilities and secondary disabilities that result from primary substance abuse as this is deemed to constitute willful misconduct on the part of the claimant. See 38 U.S.C. § 105 (a); 38 C.F.R. §§ 3.1 (m), 3.301(d); see also Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001) (“the legislative history is quite clear that Congress intended to... preclude recovery for a primary alcohol abuse disability...”). However, service connection may be warranted for an alcohol or substance abuse disability acquired as secondary to, or as a symptom of, a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff’d sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and “may provide sufficient support for a claim of service connection.” Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the veteran’s present condition (e.g., whether the condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology; rather, such issue may be established by competent and credible lay evidence. depending on the facts of the particular case, under 38 U.S.C. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, VA treatment records during the appeal period note various psychiatric diagnoses. For example, VA treatment records from approximately mid-2009 through 2010 document ongoing mental health treatment primarily focused on maintaining sobriety. Many of those VA therapy notes (including several by intern D.M., M.S. under the supervision of Dr. W.M., Psy.D.) note diagnoses of alcohol dependence in sustained, full remission and polysubstance dependence in sustained full remission. Mid-2009 VA social work notes by A.B.S., LCSW note diagnoses of adjustment disorder with mixed depressed mood and anxiety, R/O (rule out) PTSD, and depressive disorder NOS, rule-out PTSD. See March, April, and June 2009 VA social work notes. After an April 2016 motorcycle accident, the Veteran resumed ongoing, regular VA mental health care pursuant to a local veteran’s court program. The focus of this treatment again was primarily managing the Veteran’s sobriety, as well as his coping with the legal consequences of the accident. Several VA social work notes from approximately fall 2016 through 2017 note diagnoses of an anxiety disorder and alcohol dependence (in early remission). See, e.g., September 2016, October 2016, February 2017, March 2017, April 2017, and June 2017 VA social work notes. However, other VA treatment records around same period note the Veteran denied depressed mood or anxiety. See February 2017 and February 2018 VA primary care notes. Furthermore, a July 2014 VA treatment record notes a positive PTSD screen based on the Veteran’s endorsement of some symptoms associated with PTSD. However, most other PTSD screens of record during the appeal period were negative based on the Veteran’s denial of PTSD symptoms. See, e.g., July 2012, July 2013, July 2015 VA PTSD screens. During an August 2009 VA examination by Dr. L.E., PhD, the Veteran reported symptoms such as nightmares related to his injury, and brief memories of when he was wounded daily, which he did not describe as particularly distressing. Moreover, the Veteran reported some physiological reaction to unexpected or loud noises, and positioning himself in public places to see windows and doors in public places. The Veteran also reported close relationships with his girlfriend and children. The examiner found that overall, the Veteran’s description of events did not involve the frequency or severity of symptoms necessary for a DSM-IV diagnosis of PTSD. The examiner found psychometric test results were consistent with the interview in that the Veteran reported some symptoms of PTSD; however, the examiner noted that even these criteria did not meet the level typically found among veterans with a PTSD diagnosis. Moreover, although the Veteran’s Beck Depression Inventory-II score was consistent with severe depression, the examiner found that this appeared to reflect some over-reporting of symptomatology. Despite the examiner’s acknowledgment that the Veteran was over-reporting depression symptoms, the examiner diagnosed the Veteran with depressive disorder not otherwise specified (NOS) unrelated to military service. The examiner also diagnosed alcohol dependence reportedly in full sustained remission, and cannabis abuse reportedly in full sustained remission. The examiner found that the Veteran’s longstanding history of excessive alcohol and marijuana use likely played the most significant role in some of his irritability and history of aggressiveness and violence. The examiner explained that these substances increase irritability, mood instability, sleep disruption, and impulsivity. In a June 2016 remand, the Board deemed the August 2009 VA PTSD examination inadequate to the extent that it failed to explain which diagnostic criteria were and were not met under the DSM-IV criteria (which were in effect at the time of the 2009 examination). In September 2016, the Veteran was afforded another VA examination by clinical psychologist E.H., PsyD. The only noted DSM-5 diagnosis was alcohol use disorder, in early remission. The Veteran expressed his belief that he may have PTSD based on bad memories of his Vietnam War experiences. He reported symptoms such as a flashback one year ago and getting emotional during movies. However, he denied nightmares, avoiding people or places, or expending significant energy trying to avoid thoughts of war. The Veteran also described a longstanding sense of regret regarding his Vietnam service, but that this symptom did not significantly impact him in the past year. Other than dysthymic mood with constricted range of affect, most other behavioral observations on examination were negative or normal. The examiner determined that the Veteran did not have a diagnosis of PTSD that conformed to the DSM-5 criteria based on the current examination because the intensity and frequency of his symptoms did not warrant a diagnosis. Specifically, the Veteran reported that his last re-experiencing symptom occurred approximately one year ago, and he reported avoiding certain movies but denied avoiding any other stimuli to avoid thinking about the war. The examiner also noted that the Veteran denied expending significant effort trying to avoid thoughts of war. The VA examiner considered a possible diagnosis of an adjustment disorder related to recent life stressors; however, the examiner ultimately ruled out this diagnosis given the Veteran’s subjective impression that he was handling stress reasonably well. In September 2019, the Veteran underwent another VA examination by clinical psychologist E.H., PsyD. The only noted DSM-5 diagnosis was alcohol use disorder in full remission. The Veteran reported positive family relationships, a “good” overall social life, and various solitary and social hobbies. He denied any emotional difficulties with activities of daily living other than some procrastination. He reported re-experiencing symptoms near the time of his birthday and that the last combat-related flashback had occurred two years ago. He also reported anxiety triggered by combat-related reminders such as movies, but that this was not particularly problematic or distressing for him. He also reported road rage two to three times per year and denied chronic irritability or aggression. He described his overall mood as “good” other than occasional sadness when thinking about financial concerns and occasional feelings of regret regarding past infidelity. He denied anhedonia, problems with motivation, interpersonal withdrawal, and low energy. On examination, all behavioral observations were negative or normal. Psychometric testing results and the PTSD Checklist for DSM-5 were below the cutoffs required for a PTSD diagnosis. The September 2019 VA examiner concluded that the Veteran did not have a diagnosis of PTSD that conformed to the DSM-5 criteria based on the evaluation, the Veteran’s medical records, the Veteran’s own descriptions of his symptoms and impairment, and scores on psychometric measures. Specifically, the examiner found that the severity of the Veteran’s symptoms in terms of frequency and intensity did not satisfy Criteria B and E for a PTSD diagnosis. For example, the examiner acknowledged the Veteran’s report of anxiety triggered by combat-related movies, which is potentially indicative of symptoms within Criteria B and E for a PTSD diagnosis; however, the veteran stated that such anxiety was not particularly problematic or distressing for him, as it only lasted for a few minutes at a time and he did not dwell on it. When the examiner expressly asked the Veteran whether he underreported combat-related anxiety, the Veteran affirmatively denied this. Moreover, when asked about re-experiencing symptoms (Criterion B), the Veteran estimated that his last flashback occurred a couple of years ago, and that he generally relives combat approximately once a year, on his birthday. The examiner reasoned that these findings were largely consistent with the prior, September 2016 VA examination, which also indicated below-threshold frequency of reexperiencing symptoms. In summary, the September 2019 VA examiner opined that the Veteran did not meet the criteria for a PTSD diagnosis because he denied any clinically significant distress or impairments within important areas of functioning, and his symptoms were either too infrequent or too low in intensity. Furthermore, the September 2019 VA examiner opined that the Veteran did not meet the criteria for depressive disorder or any other psychiatric disorder. The examiner reasoned that the Veteran reported good mood, denied all symptoms of major depressive disorder, and described contentment with the quality of his life. He also stated that he had been emotionally stable since quitting alcohol three years ago. The September 2019 VA examiner also found that the Veteran did not meet the criteria for an anxiety disorder or any other psychiatric disorder. The September 2019 examiner acknowledged 2016 and 2017 VA social work notes referring to anxiety symptoms and the Veteran did recall worrying at that time; however, the Veteran stated those anxieties pertained to legal issues related to a DUI charge. At the time of this examination, the Veteran reported remission of anxiety since he stopped drinking and was no longer concerned about DUIs. In a February 2020 VA medical opinion, psychologist M.R.M., PhD, reviewed the record, including prior diagnoses of depressive and anxiety disorders by other VA examiners and treating clinicians, and concluded that these prior diagnoses were made in error. Regarding the August 2009 VA examiner’s diagnosis of depression NOS, the February 2020 VA examiner found that this diagnosis was internally inconsistent with findings elsewhere in the August 2009 VA examination report. For example, the August 2009 VA examiner noted the Veteran overreported symptoms during psychological testing; however, the Veteran also reported “good” mood and sleep and relatively low depression and anxiety. Since the 2009 VA examiner’s diagnosis of depression NOS was based on the Veteran’s high reporting on depression test measures, which was inconsistent with the Veteran’s denial of various depression symptoms during the examination, this diagnosis was invalid. Moreover, the 2009 VA examiner failed to diagnose the Veteran’s well-documented, longstanding alcohol abuse disorder, or to consider how alcohol abuse causes depressive-like symptoms that mimic depression. Regarding a VA social worker’s diagnoses of anxiety disorder NOS in 2016-2017, the February 2020 VA examiner explained that this diagnosis also was made in error, “in that anxiety about the real possibility of going to jail for obtaining one’s 5th DUI is a realistic concern and not one in excess of the situation, nor did it cause impairment required for the diagnosis of a mental disorder.” The 2020 VA examiner further explained: Of note, the recent exams show that ther[e] have been no significant mental health symptoms since the [V]eteran stopped drinking alcohol; further evidence that any irritability in mood in the past such as anxiety or depressive symptoms effects, effects of the cycle intoxication and withdrawal and worries about the real consequences of his alcohol use. As such, past diagnoses of depression or anxiety were in error and were likely actually an alcohol induced depressive or anxiety disorder, that resolved once the [V]eteran stopped drinking. After a full review of the evidence of record summarized above, the Board must deny the claim. The weight of the most competent, probative, and persuasive medical evidence does not show a valid, current DSM-5 psychiatric disability other than noncompensable diagnoses of primary alcohol and substance abuse disorders in remission. Initially, to the extent that the Veteran seeks entitlement to service connection for the documented, primary alcohol and substance abuse disorders in remission as directly related to service, the claim is denied as a matter of law because these are not disabilities for the purposes of VA compensation. See 38 U.S.C. § 105(a); 38 C.F.R. §§ 3.1(m), 3.301(d); see also Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001) ("the legislative history is quite clear that Congress intended to ... preclude recovery for a primary alcohol abuse disability..."). The Board affords great probative value to the September 2019 VA examiner’s opinion that the Veteran did not satisfy the clinical criteria for a PTSD diagnosis under the DMS-5. As discussed in detail above, the 2019 VA examiner fully explained why the Veteran’s symptomatology reported and shown on examination were not severe enough to warrant a current DSM-5 diagnosis of PTSD. The examiner based this finding on a thorough evaluation, as well as consideration of the Veteran’s medical records, the Veteran’s own descriptions of his symptoms and impairment, and scores on psychometric measures. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The Board acknowledges the July 2014 VA treatment record noting a positive PTSD screen based on the Veteran’s endorsement of some symptoms associated with PTSD. However, most other PTSD screens of record during the appeal period were negative based on the Veteran’s affirmative, consistent denial of PTSD symptoms. See, e.g., July 2012, July 2013, July 2015 VA PTSD screens. Therefore, viewed in light of the totality of the evidence of record, the July 2014 VA positive PTSD screen is an isolated outlier. The Board also affords this PTSD screen by an R.N. less probative weight than the 2019 VA examiner’s contrary finding because the 2019 VA examiner, a psychologist, found the Veteran did not meet the DSM-5 criteria for a PTSD diagnosis based on a much more comprehensive psychological evaluation and record review. Likewise, the Board considered mid-2009 VA social work notes noting a differential diagnosis of R/O (rule out) PTSD. However, the Board affords this finding less probative weight than the 2019 VA examiner’s contrary finding. The 2019 VA examiner found the Veteran did not meet the DSM-5 criteria for a PTSD diagnosis based on a much more comprehensive psychological evaluation and record review. Unlike the VA treating social worker, the 2019 VA examiner extensively explained why various DSM-5 criteria for a PTSD diagnosis were unsatisfied, despite the Veteran’s endorsement of some symptoms associated with PTSD. Moreover, although the VA treating social worker (L.C.S.W.) was competent to evaluate and treat mental disorders, the 2019 VA examiner, a clinical psychologist (PsyD), had more extensive training, expertise, and experience. Furthermore, the Board affords great probative value to the February 2020 VA examiner’s findings regarding the absence of any current mental disorders during the appeal period other than alcohol and substance abuse disorders in remission. This opinion was based on a very thorough review of the Veteran’s pertinent medical history, was neither equivocal or speculative, and was supported by reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl, 21 Vet. App. at 124. The February 2020 VA examiner fully explained why prior VA examiners and treating clinicians erroneously diagnosed the Veteran with various non-PTSD psychiatric disorders, to include anxiety disorder NOS, depression NOS, and an adjustment disorder, as discussed in detail above. In contrast, the Board affords minimal probative value to the August 2009 VA examiner’s depressive disorder NOS diagnosis. This diagnosis was made in error for the reasons persuasively and extensively set forth in February 2020 VA psychological opinion. Specifically, this diagnosis was internally inconsistent with findings elsewhere in the August 2009 VA examination report and failed to account for the Veteran’s well-documented alcohol abuse disorder, which can cause symptoms that mimic depression. The Board considered VA treatment records during the appeal period that noted various non-PTSD diagnoses, namely anxiety disorder NOS, adjustment disorder with mixed depressed mood and anxiety, and depression NOS. However, as the February 2020 VA psychological examiner persuasively and thoroughly explained, the treating providers’ anxiety diagnoses were erroneous. Those VA treatment notes documented the Veteran’s justified anxiety about the real possibility jailtime due to a DUI charge, as opposed to anxiety in excess of the situation. Moreover, the Veteran’s reported anxiety during those encounters did not cause any impairment. Therefore, as competently and persuasively noted by the February 2020 VA examiner, the Veteran’s reported anxiety during these encounters did not meet the clinical criteria for a mental disorder. Moreover, the February 2020 VA examiner persuasively explained that past diagnoses of depression or anxiety were in error as they were likely actually an alcohol-induced depressive or anxiety disorder, which resolved once the Veteran stopped drinking. The VA treating clinicians who made these diagnoses – a supervised psychology intern (M.S.) and a licensed clinical social worker (LCSW) – were competent to diagnose psychiatric disabilities; however, the Board affords more probative weight to the February 2020 VA examiner’s contrary findings because the 2020 examiner has more extensive mental health training, expertise, and experience as a clinical psychologist (PhD). The Board recognizes the Veteran’s contention that he has current psychiatric disorders, to include PTSD. As a lay person, he is competent to report observable mental health symptoms he experiences, such as subjective feelings of anxiety and irritability. However, he is not competent to self-diagnose a psychiatric disability because this requires specialized mental health expertise and training. Therefore, the Board affords these lay assertions minimal probative value. Based on the weight of the most competent, probative, and persuasive evidence summarized above, there was no valid diagnosis for PTSD or any other psychiatric disability other than noncompensable, primary alcohol and substance abuse disorders in remission during appeal period. Without evidence of a current, validly diagnosed, compensable psychiatric disability, service connection cannot be granted. See Martinez-Bodon, 32 Vet. App. at 401, 404. Therefore, the Veteran’s claim must be denied. Finally, the Board acknowledges the Veteran’s contention that the August 2009 VA psychological examination was inadequate. Specifically, the Veteran contends that the examiner’s finding that he did not meet the diagnostic criteria for PTSD inadequately considered his service personnel records and combat service. See August 2012 VA Form 9. However, contrary to this contention, the 2009 VA examiner did consider the Veteran’s pertinent military history, to include the circumstances of his Vietnam War service. The Board has not relied on the 2009 VA examination in this decision to the extent that the June 2016 Board remand deemed it inadequate. Specifically, the Board found that the August 2009 VA examiner failed to explain which PTSD diagnostic criteria were and were not met under the DSM-IV. The Veteran has not raised any other duty to notify or duty to assist issues. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 2. Entitlement to a TDIU is granted. The Veteran maintains that he is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. A TDIU is warranted where the evidence of record shows that a Veteran is unable to secure or follow a substantially gainful occupation, consistent with his education and occupational experience, as a result of service-connected disability, without regard to advancing age. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). If there is only one such disability, it must be rated at 60 percent or more. If there are two or more 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. §§ 3.340, 3.341, 4.16(a). For the purpose of determining one 60-percent disability, or one 40-percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3) disabilities affecting a single body system (e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric); (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). In the present case, the Board finds that the threshold requirements for a schedular award of a TDIU have been met. The Veteran is currently in receipt of compensation for the following service-connected disabilities: coronary artery disease rated as 30 percent disabling; type II diabetes mellitus rated as 20 percent disabling; residuals from a shell fragment wound of the right foot rated as 10 percent disabling; residuals of a separated right shoulder rated as 10 percent disabling; residuals of a shell fragment wound of the neck rated as 10 percent disabling; residuals of a shell fragment wound of the right lower extremity rated as 10 percent disabling; compression fracture deformity of the low back rated as 10 percent disabling; Pellegrini-Stieda’s disease of the right knee rated as 10 percent disabling; tinnitus rated as 10 percent disabling; residuals of shell fragment wounds to the right upper extremity and left lower extremity rated as noncompensable (zero percent disabling); bilateral cataracts rated as zero percent disabling; bilateral hearing loss rated as zero percent disabling; erectile dysfunction associated with coronary artery disease rated as zero percent disabling; neuropathy of the right lower extremity rated as zero percent disabling. These service-connected disabilities, when combined, are 70 percent disabling throughout the appeal period. With regard to the 40 percent criteria set forth in 38 C.F.R. § 4.16(a), the Board has applied the combined ratings outlined in 38 C.F.R. § 4.25. The Veteran’s CAD has been rated as 30 percent throughout the appeal period and his type II diabetes has been rated as 10 percent from June 26, 2009 and 20 percent from November 19, 2010. Because these disabilities have a common etiology (Agent Orange exposure), they may be combined to count as “one disability” under § 4.16(a). The result is a rating that rounds to 40 percent beginning June 26, 2009. Thus, the Veteran has satisfied the schedular criteria for consideration of a TDIU throughout the appeal period. In Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court provided a list of potentially relevant factors to be considered in determining whether a Veteran can secure and follow a substantially gainful occupation under 38 C.F.R. § 4.16. Pertinent to the present appeal, the Court found that consideration of a Veteran’s physical ability is necessary, with possible relevant factors including the Veteran’s limitations as to lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as audio and visual limitations. In September 2013, the Veteran underwent several VA examinations. The VA examiner found that multiple service-connected disabilities did not functionally impact the Veteran’s ability to work, but provided no supporting rationale. However, the examiner also found that the Veteran had multiple (unspecified) medical conditions that would render him unemployable in a physical environment, “but sedentary employment could be explored.” In September 2016, the Veteran underwent several VA examinations to evaluate the functional impacts of his service-connected disabilities. The examiner opined that the Veteran’s CAD would adversely impact his ability to work. She explained that the Veteran “would not be able to do a job that is [a] highly physically demanding labor type of job day [in] and day out given that he had small area of reversible perfusion.” She suggested, however, that he would be able to perform “sedentary work”. See September 2016 VA heart conditions examination. With regard to the impact of his low back disability, the September 2016 examiner explained that the Veteran would have difficulty maintaining work that is highly physically laborious, “as was his career before retirement.” The examiner also noted that the Veteran “would have difficulty maintaining work that required him to repetitively bend, lift, or carry any weight greater than 25 or 30 pounds for a full workday.” See September 2016 VA back examination. With regard to the impact of his disabilities of the lower extremities, the examiner opined that the Veteran would have difficulty maintaining a job that was highly laborious and required “repetitive climbing, crawling, kneeling, or squatting for an entire workday.” See September 2016 VA knee and lower leg examination. Regarding the service-connected right shoulder disability, the September 2016 VA examiner found that the Veteran is unable to do work that is highly physically demanding, but that he would be able to do any “sedentary” or “light” work without restriction. Specifically, the examiner opined he would have difficulty maintaining work that would require him to carry weights repetitively beyond 30 to 50 pounds, repetitively reach overhead, or use a hammer. See September 2016 VA shoulder and arm examination. Here, the record reflects that the Veteran has a high school education. His past work experience is comprised almost entirely of rigorous physical labor—working 30 years as part of the block and brick crew for a construction company. Given the Veteran’s actual occupational and employment history, the Board finds that the 2013 and 2016 VA examination findings suggesting the Veteran would be employable in a “sedentary” role are highly speculative and conclusory. In contrast, the Board affords more probative weight to the 2013 and 2016 VA examiners’ favorable findings summarized above indicating that various service-connected disabilities would preclude physically demanding work because these findings accounted for the Veteran’s actual vocational history. Therefore, the evidence is at least in equipoise that the combined effects of the Veteran’s service-connected disabilities – namely CAD, right shoulder separation residuals, the lumbar spine disability, and the right knee disability – have rendered him unable to secure or follow substantially gainful employment throughout the appeal period. Entitlement to a TDIU is therefore granted. In Bradley v. Peake, 22 Vet. App. 280, 294 (2008), the Court determined that a separate TDIU rating predicated on one disability, when considered together with another disability or disabilities separately rated at 60 percent or more could warrant special monthly compensation (SMC) under 38 U.S.C. § 1114(s). However, in this case, the Board has awarded TDIU based on the combined effects of multiple service-connected disabilities. A TDIU rating based upon multiple disabilities does not meet the single disability requirement set forth in 38 U.S.C. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242 (2010). Therefore, an inferred SMC claim has not been raised. R. JANOFSKY Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board F. Lanton, 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.