Citation Nr: 21003902 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 18-10 043 DATE: January 25, 2021 ORDER Entitlement to a 50 percent rating for posttraumatic stress disorder (PTSD) prior to February 17, 2020 is granted. Entitlement to a rating in excess of 70 percent for PTSD, beginning February 17, 2020, is denied. Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU), prior to March 22, 2017 is granted. FINDINGS OF FACT 1. For the appeal period prior to February 17, 2020, the Veteran’s PTSD manifested in occupational and social impairment with reduced reliability without deficiencies in most areas or total social and occupational impairment. 2. For the appeal period beginning on February 17, 2020, the Veteran’s PTSD manifested in occupational and social impairment with deficiencies in most areas without total occupational and social impairment. 3. For the appeal period prior to March 22, 2017, the Veteran’s service-connected disabilities rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. For the appeal period prior to February 17, 2020, the criteria for assigning a rating of 50 percent, but not higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.125, 4.126, 4.130, Diagnostic Code 9411. 2. For the appeal period beginning February 17, 2020, the criteria for assigning a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.125, 4.126, 4.130, Diagnostic Code 9411. 3. For the appeal period prior to March 22, 2017, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1967 to June 1969, to include service in the Republic of Vietnam. The Veteran’s awards and decorations for his service include a Bronze Star Medal, Combat Infantryman Badge, Republic of Vietnam Cross of Gallantry with Palm, among many others. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Muskogee, Oklahoma. Jurisdiction of this appeal is currently with the RO in Montgomery, Alabama. This case was most recently before the Board in January 2020, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. On remand, in an October 2020 rating decision, the AOJ increased the rating for the Veteran’s PTSD to 70 percent, effective February 17, 2020; and granted entitlement to a TDIU, effective March 22, 2017. This is not the maximum possible rating and the RO correctly concluded that the increase in rating was a partial (not full) grant of the benefit being requested and, therefore, did not abrogate the pending appeal. But this appeal now concerns whether the Veteran is entitled to an even higher rating for the entire period on appeal, meaning a rating even greater than 70 percent beginning February 17, 2020, a rating in excess of 30 percent to February 17, 2020; and entitlement to a TDIU prior to March 22, 2017. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). Accordingly, the Board has recharacterized the issues as shown on the cover page of this decision. The case has now been returned to the Board for appellate action. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ) of the Board in October 2019. A transcript of the hearing has been associated with the claims file. 1. Increased Rating – PTSD The Veteran asserts that he should be in receipt of higher ratings for his PTSD as his symptoms are more severe than that which is reflected by the current ratings assigned. Specifically, the Veteran and his wife assert that his symptoms have worsened following a firing range being built near their home, and that his symptoms result in significant interference with his life and family relationships. See generally, Lay Statements, August 12, 2016. Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant’s current symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. The Veteran is rated at 30 percent disabling prior to February 17, 2020, and 70 percent thereafter for his PTSD. The criteria for evaluating PTSD is found in the General Rating Formula for Mental Disorders, under 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is warranted where there is occupational and social impairment due to mild or transient symptoms which would decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. Id. A 50 percent rating is warranted where 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and, difficultly in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is 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 inability to establish and maintain effective relationships. Id. A 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and, memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed above serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442 – 44 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the Veteran’s capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126(a). In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, 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 on the basis of social impairment. The Board notes that with regard to the use of the phrase “such as” in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in December 2020. As such, the DSM-5 applies, and the GAF scores will not be considered. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claims. A veteran need only demonstrate that there is an approximate balance of positive and negative evidence to prevail in a service connection claim. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). When the evidence for and against the claim is in equipoise, by law, the Board must resolve all reasonable doubt in favor of the appellant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Turning to the evidence, May 2015 and March 2016 VA treatment records indicates the Veteran attended a counseling appointment with his VA mental health provider. At that time, the Veteran reported difficulty with low frustration tolerance, poor sleep, nightmares, increased startle response and intrusive thoughts about combat experiences in the Republic of Vietnam. He denied suicidal or self-harm thoughts or intent, and noted protective factors included religious believes, hopes and plans for his future, social support at home and social support in the community. Typical presentation of the Veteran during this time included casual appropriate dress, alert and oriented to time, person, place, and situation, cooperative demeanor, dysphoric mood, congruent affect and no perceptual disturbances. See e.g. May 2015, September 2015, and March 2016 VA treatment records. The Veteran was afforded a VA examination in April 2016. At that time, the examiner found the Veteran’s PTSD was manifested by 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 routing behavior, self-care and conversation. The Veteran reported that he believed he had a good relationship with his wife, but that she may feel otherwise because he had “been through a lot putting up with [him],” and that she said he had a “short fuse.” The Veteran had three adult sons, and described his relationships with them as “good.” He lived with his wife. His parents and two brothers were deceased. He maintained contact with his surviving brothers who lived nearby, and saw his sisters occasionally. The Veteran also reported having two friends that he saw on occasion; and stated he kept his distance from most people. Hobbies and interests included fishing in the summer, but the Veteran reported he had difficulty getting around due to his knees. He reported he used to like to attend baseball games but no longer attended sports and he did not like the fireworks. He reported he used to like to sit on his porch, but with the addition of a new firing range nearby he typically stayed inside. He read and liked to visit his children occasionally; however, he had not visited in about a year due to trouble driving as a result of his knee. He reported that loud noises on the road are “nerve wracking.” He attended church on Sundays. He reported a firing range was built about nine months prior, and that his had worsened his PTSD symptoms. Symptoms attributable to his PTSD included depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment and mild memory loss, such as forgetting names, directions or recent events. Behavioral observations showed the Veteran was casually dressed, had good grooming and hygiene, speech within normal limits, good eye contacts, thoughts logical and goal-directed, ambulating with a cane and was oriented to time, place, person but missed the date by one day. The examiner further noted that the Veteran had normal memory and attention for evaluation purposes, but was not formally assessed, abstract reasoning withing normal limits, “fairly decent” mood and neutral affect. The Veteran endorsed a chronically depressed mood, fair appetite, a history of transient suicidal ideation without current suicidal ideation, plan, or intent reported and no suicide attempts reported since his last VA examination, and identified his family and spirituality as protective factors. Other symptoms were reported to include sleep problems, sleeping about five hours daily and more disruptive sleep after the firing range was built, nightmares four to five times per week, daytime fatigue, irritability, a “short fuse” that was getting “shorter” and no current active homicidal ideation, intent, or plan. The Veteran also reported no obsessive compulsive disorder type symptoms reported, anxiety, which had been exacerbated by the firing range, and anxiety exacerbated by scenes of violence on television, enhanced startle response and thoughts often focused on this during evaluation, such as, almost knocking items off of a table when hearing a loud noise, panic attacks, heightened anxiety in relation to loud noises, memory problems, some visual hallucinations, such as seeing at times during the day a radio operator that was shot during service, worsening PTSD symptoms and thoughts of service that “seem like it happened yesterday.” Of record is a June 2016 letter submitted by the Veteran’s mental health providers, S.J., LCSW-PIP, and Dr. E.H. In that letter, they state that the Veteran had “major difficulty functioning in all aspects as a result of the debilitating symptoms of PTSD.” A July 2016 statement submitted by the Veteran’s wife indicated that the Veteran’s current symptoms include nightmares, night sweats, fighting in his sleep, shutting down; not wanting to go outside, panic attacks, sensitivity to loud noises, fear of hurting people, “hollering and screaming” at her without reason, quick to anger, being upset, being difficult to deal with at times, short- and long-term memory problems, worsening symptoms, being highly disturbed due to memories of combat, little or no interest in attending social activities, difficulty getting along with family and friends, difficulty in understanding and following instructions, cannot “absorb things,” difficulty with speaking, flashbacks as a result of the firing range and being frantic and agitated. She stated that every day was a challenge. A July 2016 statement submitted by the Veteran indicated that his condition had been aggravated by a new gun firing range that was built near his home. He stated that on some days, it felt as though he was in combat all over again. Current symptoms reported included difficulty sleeping, hallucinations, out of control behavior, violent episodes around his wife and kids reexperiencing traumatic events, flashbacks, nightmares, anxiety, fear, anger, that caused him to defend himself, some interest in things he used to do, emotionally and physically down and depressed, major difficulties functioning in all aspects as a result of his PTSD symptoms. A February 2018 VA treatment record indicates the Veteran attended a counseling appointment with his VA mental health provider. At that time, the Veteran reported he had been having some down feelings lately. He denied any harmful ideation, plan, or intent. Typical presentation of the Veteran during this time included casual appropriate dress, alert and oriented to time, person, place, and situation, cooperative demeanor, mildly anxious mood, congruent affect and no perceptual disturbances. See e.g. February 2018 VA treatment record. In a July 2018 letter submitted by the Veteran’s mental health providers, S.J., LCSW-PIP, and Dr. E.H., the providers opined that the Veteran had been unable to sustain meaningful employment since 1997 and noted that it was the opinion of his mental health treatment team that the Veteran would not be able to sustain employment due to the severe, debilitating symptoms of PTSD. In that regard, they noted that the Veteran had major difficulty with symptoms such as an increased startle response, low frustration tolerance, nightmares and major sleep difficulty. They recommended that the Veteran be scrutinized for unemployability based on his current low baseline of functioning, and noted that his prognosis was not likely to improve above such baseline. The Veteran and his wife testified at a Board hearing in October 2019. At that time, the Veteran and his wife testified that the Veteran’s PTSD symptoms included impaired sleep, nightmares, staying inside the home, and difficulty leaving the home due to the nearby firing range, wearing earmuffs outside, forgetfulness, feeling “completely batty” as a result of the firing range, short-tempered, crowd avoidance, difficulty in public, specifically with sudden loud noises, forgetting where he is going, or why he came outside and needing the assistance of his wife to travel places, and during appointments due to his memory. The Veteran testified he was short-tempered with his wife, and that she was his “backbone”; and that they had been married for 52 years. A September 2019 letter was submitted by the Veteran’s mental health providers, S.J., LCSW-PIP, and Dr. E.H. In that letter, they opined that the Veteran had been unable to sustain meaningful employment since 1997 and noted that it was the opinion of his mental health treatment team that the Veteran would not be able to sustain employment due to the severe, debilitating symptoms of PTSD. In that regard, they noted that the Veteran had major difficulty with symptoms such as an increased startle response, low frustration tolerance, nightmares and major sleep difficulty. They further noted that the Veteran experienced instances of disassociation in which he was confused and unsure of his actions for periods of time, noted difficulties with obsessive symptoms and difficulty with social anxiety. They again recommended that the Veteran be scrutinized for unemployability based on his current low baseline of functioning, and noted that his prognosis was not likely to improve above such baseline. The Veteran was afforded a VA examination in February 17, 2020. At that time, the examiner opined the Veteran’s PTSD manifested in occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, and/or mood. At this time, the Veteran continued to live with his wife of over 52 years, and stated that his wife, family, and grandchildren were very supportive. The Veteran’s wife attends his appointments, help with medication management, and was described as his “rock.” He stated that his symptoms had increased as a result of the shooting range by his house and recounted difficulty attending church as a result of his sensitivity to sounds and noises. He reported that February is the hardest month for him because it is the anniversary of the TET offensive. During this time, his children come home. The Veteran reported he had one friend, had no social life and that if he goes out, he is easily startled by the noises and overreacts to sounds. The Veteran expressed distress that his family had given up things due to his PTSD and stated he could not handle much more, but did not want to hurt himself because of his family. He reported he tried to keep busy to keep his mind off of his traumatic experiences; and he used to do yardwork, but found it was difficult to do while wearing earmuffs (to muffle the noises from the firing range). Symptoms attributable to his PTSD during the February 2020 VA examination included depressed mood, anxiety, chronic sleep impairment, impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a work-like setting. Other symptoms associated with the Veteran’s PTSD included the triggering and escalation of PTSD symptoms due to the firing range near his home, wearing earmuffs inside and outside his home, lacked motivation to get out of bed, but his children and wife push him to get up and do things and that the firing range was worse during good weather because they shoot high power weapons all day. Behavioral observations showed the Veteran ambulated with a cane, appeared frail, was clean and casually dressed, alert, oriented, pleasant and cooperative, and in no acute distress, normal speech, spontaneous and appropriate responses to questioning and sufficient attention and concentration. The examiner noted that the Veteran denied suicidal ideation and hallucinations, delusional and bizarre thinking not evidenced, unimpaired judgment, unimpaired impulse control, unimpaired insight, average intellectual functioning, based on demonstrated verbal skills, vocabulary, and fund of knowledge and appeared competent. The February 2020 VA examiner noted worsening in the Veteran’s PTSD symptoms. The examiner opined that the Veteran’s PTSD did not fully prevent the ability to do physical and sedentary work, but placed limitations on the likelihood of successful sustained employment associated with concentration or memory deficits, interpersonal challenges, mood issues, and emotional difficulties related to his PTSD. The examiner noted the Veteran might have a greater likelihood of successful sustained employment in a part-time or limited stress environment with the ability to work independently and at a slower pace with minimal direct customer contact, due to his reported memory and concentration deficits, irritability, low frustration tolerance, and difficulties being around others; and work placement should be consistent with the physical limitations of a 75 year old who is frail in appearance, ambulated with a cane, and was undergoing treatment for prostate cancer. The examiner noted that the Veteran’s mental health status would likely have the following impact on factors that relate strongly and directly to the ability to do physical and sedentary work: problems interacting effectively with supervisors, coworkers, and customers due to irritability or anger and strong tendencies to isolate, reduced work performance due to short-term memory problems, and he may have problems completing tasks correctly and efficiently, difficulty tolerating high amounts of stress and problems adapting to changes in the workplace or to new tasks that might be given to him, and he would likely function better in a job that involved more routine or repeated tasks; problems with anxiety, hypervigilance, and exaggerated startle response are likely, and he should not work in a setting with lots of people or where there are loud or unpredictable noises as these trigger flashbacks and decompensation or dissociation; and sleep disturbance and resulting fatigue may result in tardiness and difficulty remaining on task. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has reported mental health symptoms that are worse than those noted above. Based on the foregoing, the Board finds that prior to February 17, 2020, a rating of 50 percent, but not higher, for PTSD is warranted. In this regard, the Board finds that such disability was manifested by occupational and social impairment with reduced reliability and productivity without deficiencies in most areas. Impairment to mood was demonstrated as the Veteran reported low frustration tolerance and anxiety. Additionally, the Veteran reported having “out of control behavior”; being emotionally and physically down and depressed; feeling “batty”; low frustration tolerance; forgetfulness; and major difficulties in functioning in all aspects as a result of his PTSD symptoms. Further, impairment to social relations was shown by the Veteran’s reports of some limited socialization because he did not like being around groups of people. However, the Veteran did not report, and the evidence does not show that there was impairment to family relations. Rather, the Board notes that the Veteran he had a good and supportive relationship with his wife, family, children, and grandchildren. Specifically, he consistently reported that his wife was supportive of him, and assisted him with any necessary activities. Additionally, the Veteran reported “good” relationships with his three sons, and noted that his family returned home to support him in February when he had his most difficult time due to the anniversary of the TET offensive. Moreover, the Veteran reported that he had regular contact and relationships with his brothers and sisters, and indicated he had one or two friends. He reported participation in religious events, and cited his religion and family as a deterrent for suicide. Although he reported that he stayed home most of the time and reported social isolation, the Veteran also reported he continued to interact with family and attend church. No impairment to thinking was demonstrated. Some impairment to work due to his PTSD was also demonstrated. In this regard, the Veteran remained unemployed during the appeal period. Additionally, judgment was not impaired as it was consistently found to be intact or good during the appeal period. School was not attempted during the appeal period. Therefore, the Board finds that the Veteran’s PTSD showed occupational and social impairment with reduced reliability and productivity without deficiencies in most areas. Moreover, the record reflects that the Veteran’s symptoms prior to February 17, 2020 have not been consistent with occupational and social impairment with deficiencies in most areas. In this regard, the Veteran has consistently presented without impairment to thought processes or communications and has consistently denied suicidal or homicidal ideation, plan or intent, although indicating he had frequent thoughts of death. The Veteran has never shown to have impaired judgment, hallucinations, delusions, or obsessive rituals and has consistently oriented to person, place, time or place. On one occasion, the Veteran reported he saw a hallucination in the form of a radio operator that was shot during combat in Vietnam. However, there is no evidence that such hallucination was consistent nor repeated during the appeal period. There is no evidence or allegation that the Veteran’s psychiatric symptoms manifested in interference or difficulties resulted in the inability to perform activities of daily life, to include maintenance of minimal hygiene, although one instance of neglect of personal appearance hygiene was noted. Additionally, the Veteran maintained a long-term marriage and relationships with his family members, with minimal tension or discord. Moreover, this is not a disability picture indicating occupational and social impairment with deficiencies in most areas at any time during the appeal period. In addition, the Board finds that a rating in excess of 70 percent for PTSD is not warranted at any point during the appeal period. In this regard, the record reflects that the Veteran’s symptoms have not been consistent with total occupational and social impairment such that a 100 percent disability rating is warranted at any point during the period on appeal. In that regard, the Veteran has not displayed gross impairment in thought processes or communication, nor has the record shown that he is a persistent danger of hurting himself or others or grossly inappropriate behavior. The Veteran has consistently denied suicidal or homicidal ideation, plan, or intent. Additionally, homicidal or suicidal attempts were never attempted or started. Moreover, there is no evidence that the Veteran has experienced hallucinations or delusions, or obsessive rituals; with the exception of the one hallucination reported and noted above. Further, the Veteran has not displayed disorientation to time or place, or memory loss for names of close relatives, his prior occupations, or his own name. Additionally, there is no evidence or allegation that he was unable to maintain minimal personal hygiene. Mental status examinations during the appeal period consistently found the Veteran’s grooming and hygiene to be appropriate, adequate or good. There is no evidence or allegation that the Veteran’s psychiatric symptoms manifested in interference or difficulties resulted in the inability to perform activities of daily life, to include maintenance of minimal hygiene. As noted previously, the Veteran maintained a long-term marriage with his wife and maintained relationships with siblings and children. Moreover, this is not a disability picture indicating total occupational and social impairment at any time during the appeal period. In assessing the severity of his major depressive disorder, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board notes the contentions of the Veteran that the Veteran’s PTSD is more severe than currently shown on examination; and the Board observes that the Veteran and his wife, while competent to report their observable symptoms, they are not competent to report that the Veteran’s mental health symptoms are of sufficient severity to warrant a higher rating under VA’s tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). Despite the foregoing, the Board acknowledges the Veteran and his wife’s assertions that the Veteran’s symptoms worsening as a result of the firing range warrant higher ratings. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher rating are not met. See Lendenmann, supra. The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). The Board has considered whether an additional staged rating under Hart, supra is appropriate; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning staged ratings is not warranted. The Veteran and/or his representative has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that the preponderance of the evidence is for the assignment of a 50 percent rating prior to February 17, 2020, and against the assignment of a rating in excess of 70 beginning February 17, 2020 percent for PTSD. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Entitlement to a TDIU The Veteran contends that his psychiatric symptoms, in combination with his physical disabilities, prevent him from obtaining and maintaining substantially gainful employment. Specifically, the Veteran asserts that his knees interfered with the constant walking and standing required for his job, and that his PTSD symptoms and education level limited his job choices. See VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, January 28, 2020. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and 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. § 4.16(a). Rating boards should submit to the Director of Compensation Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to a TDIU is based on an individual’s particular circumstances.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran’s 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran’s master’s degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, 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 v. Brown, 4 Vet. App. 361, 363 (1993). An assessment of TDIU entitlement based on the combined effects of all service-connected disabilities should address all such disabilities. Therefore, the cumulative effects (functional impairment) of all service-connected disabilities should be addressed in determining if the service-connected disabilities prevent substantially gainful employment. Floore, 26 Vet. App. 376; accord Geib v. Shinseki, 733 F.3d 1350, 1353-54 (Fed. Cir. 2013). In making such a determination, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record and every item does not have the same probative value. The Board must analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad, 1 Vet. App. at 169. The Veteran’s credibility affects the weight to be given to his or her testimony and lay statements, and it is the Board’s responsibility to determine the appropriate weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The ultimate question is whether he is capable of performing the physical and mental acts required by employment, not whether he can find employment. 38 C.F.R. § 4.16(a); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). As of the date of this decision, service connection is in effect for PTSD, at 50 percent disabling prior to February 17, 2020, and at 70 percent disabling beginning February 17, 2020; prostate cancer, at 100 percent disabling from May 10, 2018, and at 40 percent beginning December 1, 2020; left knee disorder, at 20 percent prior to March 22, 2017, 100 percent from March 22, 2017 to May 1, 2018, and 30 percent thereafter; a right knee disorder, at 20 percent prior to August 16, 2017, 100 percent from August 16, 2017 to October 1, 2018, and 30 percent thereafter; bilateral knee scars, at noncompensable from March 22, 2017; and erectile dysfunction, at noncompensable from October 11, 2018. The combined rating is 70 percent prior to March 22, 2017; 100 percent from March 22, 2017 to December 1, 2020; and 90 percent thereafter. Therefore, as of the date of this decision, the criteria for consideration of TDIU pursuant to 38 C.F.R. § 4.16(a) have therefore been met for the entire period on appeal. Consequently, the remaining inquiry is whether such service-connected disabilities render him unable to secure and follow a substantially gainful occupation consistent with his educational and occupational background for this appeal period. In connection with his claim, the Veteran submitted a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, in January 2020. In such application, he indicated that his PTSD, prostate cancer, and bilateral knee disorders prevented him from securing or following any substantially gainful occupation. He reported that he last worked full-time in February 1997 at Anniston Army Depot. He reported that he completed high school. The Veteran stated that due to the problems with his knees, he was unable to continue the walking and standing requirements of his last job; and that as a result of his PTSD and education level, he had limited job choices following his active service. As noted in the preceding section, the Veteran’s mental health treatment providers submitted letters in June 2016, July 2018, and September 2019 indicating that the Veteran had been unable to sustain meaningful employment since 1997; and noted that it was the opinion of his mental health treatment team that the Veteran would not be able to sustain employment due to the severe, debilitating symptoms of PTSD. Additionally, the Board notes that, as of the date of this decision, the Veteran’s PTSD has been rated at 50 percent disabling prior to February 17, 2020, and 70 percent thereafter. The occupational and social impairment of his PTSD has been described in the preceding section and are incorporated herein. At May 2017 and November 2017 VA examination for his knees, the examiner found that the Veteran’s bilateral knees impacted his ability to work due to bilateral knee pain, stiffness, limited range of motion, and difficulty with pending, prolonged standing, walking, and climbing stairs. At a November 2018 VA examination for his prostate cancer, the examiner found that the Veteran’s prostate cancer impacted his ability to work due to excessive voiding and urgency that would require frequent bathroom breaks; and thus, affecting his productivity. At a June 2019 VA examination for his prostate cancer, the examiner found that the Veteran’s prostate cancer impacted his ability to work due to frequent bathroom visits that would limit his moving freely; and also impact his productivity. Based on the foregoing, and in consideration of the pertinent medical findings, including the Veteran’s reports that his barriers to employment included PTSD symptoms of chronic depression, severe anxiety, social isolation, memory problems, sleep disturbances, anger, and difficulty in establishing and maintaining effective relationships; and in combination with his prostate cancer and bilateral knee disorders, the Board finds that the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities prior to March 22, 2017. In this regard, as discussed in the preceding section, prior to February 17, 2020, the Veteran’s PTSD has been found to result in occupational and social impairment with reduced reliability. Specifically, the Board found that the severity of the Veteran’s PTSD symptoms resulted in difficulty establishing and maintaining effective relationships, anxiety, depression, anger, sleep disturbances, panic attacks, exaggerated startle response, some social isolation and most importantly unemployment. The Board notes that the Veteran had consistently reported difficulty leaving his home due to anxiety in public spaces, due to crowds, and his exaggerated responses to loud or unexpected noises. Additionally, the Veteran has consistently reported worsening of his PTSD symptoms following a firing range being built near his home. Further, the Board notes that the Veteran has remained unemployed since 1997, and for the entire period on appeal and the evidence of record indicates the continuing severity of his psychiatric symptoms prevent him from being able to meet the competitive standards for employment. See June 2016, July 2018, and September 2019 VA treatment provider letters indicating the Veteran had been unable to sustain meaningful employment since 1997 due to the severity of his PTSD symptoms. Moreover, the February 2020 VA examiner found that the Veteran’s PTSD placed limitations on the likelihood of successful sustained employment due to his PTSD symptoms; and that the Veteran would require accommodations such as part-time work, limited stress environment, ability to work independently and at a slower pace, and with minimal direct customer contact. Further, the February 2020 VA examiner noted the employment would also need to accommodate the Veteran’s age, physical limitations, frail appearance, prostate cancer, and use of a cane. Moreover, the VA examiners of record noted that the Veteran’s bilateral knees and prostate cancer would impact the Veteran’s ability to perform physical requirements of employment, and would impact his productivity. Therefore, the Board finds that in this case, the Veteran’s post-service employment required walking, standing, and reasonably required direct interaction with customers, supervisors, and other co-workers; all of which are significantly impacted by his PTSD symptoms, bilateral knee disorders, and prostate cancer. Accordingly, the Veteran’s service-connected PTSD, bilateral knee disorders, and prostate cancer; and in combination with his education level of a high school diploma would render the Veteran unable to secure and follow a substantially gainful occupation. Therefore, based on the foregoing and resolving all reasonable doubt in favor of the Veteran, the Board concludes that he is unable to secure or follow a substantially gainful occupation consistent with his education and work history beginning prior to March 22, 2017. As such, entitlement to TDIU is warranted prior to March 22, 2017. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, 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.