Citation Nr: 21063819 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 11-27 918 DATE: October 18, 2021 ORDER 1. Entitlement to increases in the initial (50 percent prior to August 6, 2013 and 70 percent from that date) staged ratings for posttraumatic stress disorder (PTSD) with alcohol use disorder and unspecified depressive disorder is denied. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is granted from [the earlier effective date of] July 21, 2017. FINDINGS OF FACT 1. Prior to August 6, 2013, the Veteran's PTSD with alcohol use disorder and unspecified depressive disorder is shown to have been manifested by a disability picture reflecting occupational and social impairment no greater than reduced reliability and productivity with difficulty in establishing and maintaining effective work and social relationships; occupational and social impairment due to PTSD with deficiencies in most areas was not shown. 2. From July 20, 2017 to December 14, 2017, the Veteran's PTSD with alcohol use disorder and unspecified depressive disorder is not shown to have been manifested by total occupational and total social impairment. 3. From July 21, 2017 (the day following the date on which the Veteran last worked full-time) to December 14, 2017, the evidence reasonably shows that the Veteran's service-connected disabilities were of such nature and severity as to have prevented him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. Increases in the initial staged (50 percent prior to August 6, 2013 and 70 percent from July 20, 2017 to December 14, 2017) ratings for PTSD with alcohol use disorder and unspecified depressive disorder are not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Codes (Codes) 9411, 9435. 2. A TDIU rating is warranted from the earlier effective date of July 21, 2017. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from January 1989 to January 1993. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2010 Department of Veterans Affairs (VA) rating decision which granted service connection for PTSD, rated 30 percent, effective November 24, 2009. An interim (March 2016) rating decision increased the rating for PTSD to70 percent, effective August 6, 2013. In June 2016, a hearing was held before the undersigned in Washington, DC. In September 2016, the Board remanded the case to the Regional Office (RO) for additional development of the PTSD rating claim. A February 2018 Board decision granted a 50 percent rating prior to August 6, 2013 and denied a rating in excess of 70 percent from that date. (A September 2019 rating decision implemented the Board's award.) The Veteran appealed the Board's February 2018 decision to the United States Court of Appeals for Veterans Claims (CAVC). An October 2018 CAVC Order granted an October 2018 Joint Motion for Remand (JMR) of the parties, thereby vacating that part of the Board's decision that denied a rating in excess of 50 percent prior to August 6, 2013 and a rating in excess of 70 percent from that date and remanding the matter to the Board for action consistent with the JMR. A March 2019 rating decision granted a TDIU rating, effective December 14, 2017 (date of receipt of a TDIU application); the rating decision re-characterized the PTSD issue to include alcohol use disorder and unspecified depressive disorder. The issue of entitlement to a TDIU rating prior to December 14, 2017 was added to the appeal because a TDIU claim is part of an increased rating claim when a TDIU claim, as here, is asserted by the Veteran or raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). A November 2019 final Board decision dismissed the appeal seeking a rating in excess of 70 percent for PTSD from August 6, 2013 to July 20, 2017 and from December 14, 2017, and remanded the case to the RO for additional development of the issues now returned to the Board for consideration. 1. Entitlement to increases in the initial staged ratings for PTSD with alcohol use disorder and unspecified depressive disorder The Veteran asserts higher staged ratings for his mental disability are warranted based on the severity of his symptoms. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. With initial ratings assigned with a grant of service connection, separate ratings may be assigned for separate periods based on facts found, a practice known as "staged' ratings." See Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). When evaluating the level of disability of a mental disorder, the rating agency shall consider the extent of social impairment but shall not assign an evaluation based solely on social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. The Veteran's PTSD with alcohol use disorder and unspecified depressive disorder is rated under 38 C.F.R. § 4.130, Codes 9411-9435. Ratings are assigned according to the manifestation of particular symptoms, but the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms listed following that phrase are not intended to constitute an exhaustive list, but rather serve 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 from PTSD with alcohol use disorder and unspecified depressive disorder under 38 C.F.R. § 4.130 is not restricted to symptoms listed in the rating criteria. Instead, VA must consider all symptoms of a claimant's condition that affect occupational and social impairment, including, if applicable, those identified in DSM-5. The issue remaining in this appeal is whether the Veteran's symptoms caused the level of impairment required for a disability rating of 70 percent or higher prior to August 6, 2013 and a 100 percent rating from July 20, 2017 to December 14, 2017. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for higher disability ratings, as claimed. Rather, prior to August 6, 2013, his symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating; and from July 20, 2017 to December 14, 2017, his symptoms more closely approximated the symptoms associated with a 70 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. Under the General Formula, a 0 percent rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130. Before August 6, 2013 VA treatment records, the May 2010 VA examination, and the lay statements of the Veteran and others show that the Veteran's PTSD with alcohol use disorder and unspecified depressive disorder was manifested by symptoms associated with a 50 percent rating (disturbances in motivation and mood, memory impairment, and difficulty in establishing and maintaining effective work and social relationships), and symptoms associated with a 70 percent rating (suicidal ideation and difficulty in adapting to stressful circumstances). He had many symptom manifestations that are associated with the criteria for a 30 percent rating, to include mood swings and depression (depressed mood), paranoia (suspiciousness), nervousness (anxiety), and insomnia (chronic sleep impairment). He also had symptoms that are not listed with a specific rating, such as hypervigilance, avoidance, re-experiencing, anger issues, difficulty in concentrating, anhedonia, and fatigue. He reported such symptoms on various evaluations, to include the May 2010 VA examination and on a September 2010 VA PTSD intake. The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximated the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. See 38 C.F.R. § 4.126. The Veteran's reported hypervigilance (looking over shoulder, feeling jumpy when hearing a loud noise) and re-experiencing (acting/feeling as if the traumatic events are recurring, reliving the experience as illusions/hallucinations, experiencing intense distress when exposed to reminders of stress) are similar to impaired abstract thinking and/or panic attacks more than once a week rather than near-continuous, to the extent it would affect his ability to function independently, appropriately, and effectively, contemplated by the 50 percent rating assigned. Avoidance symptoms (avoiding thoughts/feelings/conversations associated with the trauma and avoiding activities/places/people that arouse recollections of the trauma) are analogous to difficulty establishing and maintaining effective relationships, which is also contemplated by the 50 percent rating. Problems with anger issues are similar to disturbances of mood under the 50 percent criteria; they are also akin to impaired impulse control, under the 70 percent criteria, but the severity of the Veteran's episodes of irritability/anger were not shown to the extent contemplated by the 70 percent rating criteria, which provides periods of violence as a measure or example of the severity of impulse control problems. Difficulty concentrating is similar to difficulty understanding complex commands, which is covered by the 50 percent criteria. Fatigue and anhedonia are akin to disturbances of motivation, which is likewise covered in the 50 percent criteria (notably, service connection has been established for chronic fatigue syndrome, effective in June 2015, so the extent to which fatigue is attributable to PTSD is undetermined, and rating the same symptoms twice under separate diagnoses would violate the prohibition against pyramiding in 38 C.F.R. § 4.14). The Board notes that one May 2010 VA examination, the Veteran reported that he had some thoughts of suicide after he was laid off from his job (in February 2010), which is similar to persistent danger of self-harm, which is contemplated by the 70 percent (and 100 percent) criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation did not rise to the level contemplated by the 70 percent disability rating. At the time of the VA examination in 2010, he denied thoughts, intent, or a plan involving self-harm. As observed by the Veteran's representative in a March 2021 argument, the Veteran testified at the June 2016 hearing that he had "quite a few" "suicide tendencies" that was traceable "all the way back to 2009." Yet, when he had an opportunity to report suicidal ideation during all of his treatment sessions during the period, he generally denied it. In other words, his testimony is not supported by the contemporaneous record. The Board finds the probative value of the Veteran's testimony a few years after the period at issue is outweighed by the treatment records regarding whether the Veteran had suicidal ideation (and its frequency). The Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 50 percent rating. He experienced occupational and social impairment with reduced reliability and productivity. With the exception of about a year (from February 2010 to early 2011), he was employed full-time as a warehouseman. There was some question over the circumstances of his leaving his long-time (about 12 years) job in February 2010, as he was apparently accused of leaving work early to attend medical appointments (although he stated he had permission from his supervisor), and the matter was taken up in arbitration (outcome not shown in the record). He began mental health treatment in 2009 and had no history of hospitalization for a mental disorder. He was divorced but was in a long-term (10 year) relationship with his girlfriend. Socially, he primarily interacted with his family members; he denied any marked social withdrawal. On mental status examination on May 2010 VA examination, it was noted that the Veteran presented as clean, well-groomed, and casually dressed. He was polite and cooperative. He was alert, attentive, and oriented times four. His affect was of normal intensity, non-labile, and consistent with the content of the discussion. His mood was pleasant, although he demonstrated anxiety when discussing military experiences in Iraq. He reported having intrusive thoughts of such experiences multiple days a week and dreaming about Iraq (where he was under threat of a combat situation) at least 20 nights per month. He estimated having four hours of sleep per night. His appetite was fair. His speech was clear, goal-directed, spontaneous, and of normal pace and volume. He had rational thought content. There was no history of hallucinations or delusions, or of clear flashback episodes. His motivation level was fair; he was not anhedonic. He denied current suicidal ideation, intent, or plan. The VA examiner remarked that the Veteran's PTSD symptoms related to the following: intrusive thoughts, upsetting feelings of fear and sadness, and recurrent nightmares associated with his Persian Gulf War tour of duty. His symptoms did not preclude him from being able to manage all activities of daily living independently. The examiner assessed the severity of the Veteran's PTSD as mild to moderate and specifically found that the Veteran did not demonstrate any mental health problem that would preclude him from working on a full-time or consistent basis. This description of the Veteran's disability does not reflect the disability picture contemplated by criteria for a 70 percent rating. That is, perhaps with the exception of difficulty in adapting to stressful circumstances, the evidence is not suggestive of most of the criteria listed for a higher rating. Nor is there evidence of symptoms of similar type, gravity, frequency, and duration as contemplated for a 70 percent rating. VA outpatient treatment records reflect findings that are generally consistent with those recorded on the VA examination report, and they also do not support a rating higher than 50 percent. For example, the Veteran was seen several times in mid-2009 for anxiety and PTSD (he denied severe symptoms); his medication consisted of Prozac and trazadone. He denied suicidal/homicidal ideation. His mood was generally good or okay, and his affect was anxious. He had a long history of military-related nightmares. In July 2010, he presented to the VA (after a long absence) with continuing intrusive thoughts and nightmares of the military. He admitted to irritable mood but denied violence as well as suicidal/homicidal ideation. He was much stressed from being fired from his job of 12 years earlier in the year, and was looking for work. On mental status examination, he was casually dressed, and his mood was "okay." His affect was anxious (he became tearful when discussing PTSD issues). His thought content was logical, and his attention, concentration, and insight/judgment were fair. His depression and anxiety medication (Prozac) dosage was increased, and he was continued on his trazodone for sleep problems. In April 2011, he reported that his primary symptoms or concerns (related to traumatic military experiences) consisted of paranoia, insomnia, anger issues, nightmares, mood swings, depression, embarrassment, fatigue, hearing voices, blackouts, nervousness, and trouble with relationships. He did not feel that his symptoms affected his family life. He was satisfied with his current relationship with his girlfriend. He was under-employed, which he attributed to PTSD. He was noted to have limited social supports but also to be motivated for treatment. The Board has reviewed an April 2011 statement by a VA medical center PTSD program director. He wrote in support of the Veteran's efforts to obtain a rating higher than 30 percent "to more adequately and realistically reflect the severity of and functional impairment resulting from his PTSD." (A higher rating of 50 percent was subsequently awarded.) He noted that since the Veteran came to his attention in August 2009, he has "consistently" reported recurrent and vivid nightmares, frequent intrusive thoughts, reliving of combat/war zone experiences, significant sleep problems, occasional flashbacks with auditory and visual hallucinations, increased irritability and frustration with anger outbursts, depressed mood, lethargy, anhedonia, social withdrawal, short-term memory and concentration deficits, hyperarousal, and avoidance behavior related to military experiences. The provider felt that the severity of the Veteran's was sufficient to have significantly interfered with his occupational, interpersonal, and social functioning. The Veteran's prognosis was deemed fair and unlikely to significantly improve in the future on the basis of his continued nightmares, frequent intrusive thoughts, depressed mood, and entrenched avoidance of reminders or discussion of combat/war zone experiences. The nature of the symptoms recounted by the program director has been discussed, above, and though numerous and impactful on the Veteran's occupational and social spheres (via significant interference, according to the program director), the overall effect of them, in the Board's view, does not rise to the level of the criteria contemplated for a 70 percent rating. While such symptoms may lead to difficulty in adapting to stressful circumstances, they had not resulted in inability to establish and maintain effective relationships or led to near-continuous panic or depression (or the like) affecting his ability to function independently, appropriately, and effectively. Notably, the program director's characterization of some symptoms as being "consistently" reported by the Veteran (including occasional flashbacks with auditory and visual hallucinations, lethargy, anhedonia, and social withdrawal) is not exactly borne out in the individual counseling reports. Such records do not corroborate frequent reference to these particular symptoms, not to mention that there was evidently a fairly long (over nine months, September 2009 to July 2010) period of absence in treatment during the time from when the Veteran came to the director's attention in August 2009. Likewise, additional VA treatment records show that the Veteran's symptoms were significant, yet in the Board's judgment, they but did not rise to the severity contemplated for a 70 percent rating. In May 2011, he continued to have PTSD related issues, but his poor sleep had improved. His medication (Seroquel) for mood stability and sleep was increased. Mental status examination then showed generally the same findings as on the 2010 VA examination, except his affect was mildly anxious (he expressed frustrations he had reported having conflicts with others at work and having relational issues with his girlfriend). In July 2011, he reported feeling about the same, but indicated he had a good relationship with his girlfriend and adult son. Thus, it appears his moods were somewhat labile. In July 2011, the Veteran underwent VA neuropsychological testing, at which time he appeared to be suffering from depressive and PTSD symptoms, insomnia, and chronic pain. His use of alcohol appeared to exacerbate his medical and mental health symptoms. Testing showed cognitive difficulties, of which the etiology involved consideration of several factors to include chronic pain, fatigue/sleep difficulties, and psychiatric symptoms. It was recommended that given his "considerable PTSD and depression symptoms," he was to be encouraged to manage his symptoms more aggressively through psychotherapy and other ways. In September 2011, the Veteran reported that he was very frustrated at work and felt like hitting someone (he had conflicts with his supervisor). He vented his anger but denied suicidal/homicidal ideation. He also found medication to be relatively helpful in his struggle with anger issues. In December 2011, he reported that he was transferred to a new location at work and no longer saw the supervisor with whom he had conflicts. In January 2012, he continued to feel irritable and also disliked the noises at work because they reminded him of the military (a December 2011 record referred to the refueling of helicopters nearby). His sleep had been variable. His relationship with his girlfriend was "off and on," and he enjoyed spending time with his son. He had a negative depression screening in March 2012. In April 2012, he continued to have issues at work, and it was noted he did not really relate to or get along with several co-workers. He found counseling and his medications very helpful. He enjoyed fishing with friends and his son. He denied suicidal/homicidal ideation. Other than a mildly irritable affect, his mental status examination findings were consistent with those on the 2010 VA examination. As these records show, the Veteran's more-than-occasional symptoms were undeniably significant, as they included relationships at work and at home. Nevertheless, they also demonstrate that on balance he was still capable of functioning independently and effectively while maintaining his full-time work schedule and his quality relationships with family members and his girlfriend. He lost his job in 2010 but found another one (which records in the file show that he kept until July 2017), and his relationship difficulties with co-workers and a supervisor were more suggestive of reduced reliability and productivity consistent with the criteria for a 50 percent rating rather than impairment with deficiencies in most areas the criteria for a 70 percent rating. Some of his most persistent symptoms were disturbance of mood (depression and anxiety), sleep problems, and intrusive thoughts and nightmares, but despite such symptoms he demonstrated ability to function in occupational and social settings independently, appropriately, and to a notable extent effectively with the aid of formal mental health treatment and medication. Evidently, some cognitive dysfunction was observed on psychological testing in July 2011, which may or may not be attributable to PTSD, but the deficits shown did not reach a level of severity that precluded him from gainful employment or maintaining his social relationships. His persistent symptoms seemed to represent more of a challenge, rather than a barrier or inability, to establishing and maintaining effective work and social relationships. The Board has also considered lay statements from the Veteran, his long-term girlfriend, and family members, either in support of service connection or an increased rating (higher than 30 percent, when written). In January 2010 the Veteran expressed that he had violent dreams, continued to experience flashbacks, felt on edge all the time, disliked crowds and loud environments, was easily agitated in such environments, had poor sleep with feelings of fatigue, worried all the time and felt sad and hopeless most days, had difficulty concentrating for extended periods, became easily angered over small incidents, and felt he was unable to cope with everyday activities. His girlfriend wrote in January 2010, about his "violent dreams," difficulty concentrating on one activity, memory loss, absence of close friends and difficulty trusting others, ease at which he is angered, pervasive sadness, and inability to "get himself together" to make the changes to which he aspired. In a July 2015 statement, she reiterated that the Veteran's behavior had changed "significantly" since they began living together in 1998. She noted that for at least 5 or 6 years, the Veteran's "fun personality" had been gone and that his relationship with his own son had been "tumultuous," declining over the past 10 years. In July 2015 his brother stated that "[s]omewhere along the line we as a family have witnessed an extreme change from a happy, outgoing and nice person to an angry always agitated and aggressive individual." He briefly noted the Veteran's mood and personality changes, violent and aggressive outbursts, anxiety, nightmares, and consumption of large amounts of alcohol. In July 2015 his mother likewise described a changed man, with sleep deprivation, unhappiness, fatigue, and withdrawal from family. The foregoing descriptions of the Veteran's symptoms (to the extent that any can be attributed to the period at issue) are essentially an encapsulation of those reports documented in the 2010 VA examination report and the VA evaluation and treatment records, as previously discussed. They corroborate his considerable mental health impairment due to many different symptoms, which is not in dispute. It is the severity level of the impairment caused by such symptoms that is at issue, and the Board finds the severity of the Veteran's impairment more nearly corresponds to the criteria contemplated for a 50 percent rating. The Board notes that in March 2021 the Veteran's representative argued that the VA's use of the date of the VA examination in August 2013 to assign (the effective date for) a 70 percent rating was inappropriate because such date did not represent a "worsening" in the Veteran's symptoms but rather a description of his symptoms as they have been since 2009. This argument has little merit. The 2013 examiner did not express that the clinical findings at that time were retroactive to 2009 (in fact, the examiner acknowledged the 2010 examination showed PTSD that was mild) or identify when the Veteran's symptoms had evidently worsened; an earlier date of worsening is not shown. While the Veteran did experience symptoms contemplated by a 70 percent rating suicidal ideation and difficulty in adapting to stressful circumstancesthe evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 50 percent (or lower) rating. Further, the VA examiner felt his mental impairment was mild to moderate in severity, and VA treatment records show the Veteran's symptoms were more reflective of a disability picture with impairment characterized by reduced reliability and productivity with difficulty establishing and maintaining effective work and social relationships, rather than impairment with deficiencies in most areas and inability to establish and maintain effective relationships. From July 20, 2017 to December 14, 2017 VA treatment records and the Veteran's lay statements show that the Veteran's service-connected PTSD with alcohol use and depressive disorders was manifested by symptoms associated with a 70 percent rating (suicidal ideation, impaired impulse control, and difficulty in adapting to stressful circumstances), and little if any symptoms associated with a 100 percent rating. The records contemporaneous with this period show that he was being treated for chronic depression and social adjustment problems, and the focus of the treatment sessions was maladaptive behavior patterns, relationship problems, depression, anger management, and improved health and self-care. His assessments generally included major depressive disorder (recurrent, mild) and job and relationship stressors (identified in August 2017 and November 2017 to include traffic, previous job, physical discomfort, and low frustration tolerance), with recognition that he had periods of difficulty dealing with people and triggers of military. The Board finds the severity, frequency, and duration of the Veteran's symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. Further, even symptoms that are not specifically listed in the rating criteria, such as hypervigilance, emotional numbing, re-experiencing the trauma (flashbacks), fatigue, irritability, sleep troubles, apathy and anhedonia, and concentration troubles (identified at the March 2017 VA examination but not necessarily reflected in the numerous treatment records thereafter in 2017), are contemplated by the assigned 70 percent (or a lesser) rating. The Board notes that the Veteran has expressed suicidal ideation (see his June 2016 hearing testimony, when he described "quite a few" of them), which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). Nonetheless, the severity, frequency, and duration of any suicidal ideation had not risen to the severity level contemplated by a 100 percent rating. In fact, throughout this period, he regularly denied suicidal and homicidal ideation in the existing VA mental health treatment records. The Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 70 percent rating for occupational and social impairment with deficiencies in most areas rather than total impairment. Mental status examinations noted in VA treatment records during the period at issue and on the (preceding) March 2017 VA examination show that he presented casually dressed and groomed (i.e., no neglect of personal appearance and hygiene). He was alert, oriented, cooperative, and had good eye contact. His mood was mildly depressed or at times "okay." His immediate memory was good, but delayed recall (on the VA examination) was poor. His fund of information, communication skills, concentration, abstract thinking, insight, and judgment were either good or fair. His thoughts were clear, logical, and future-oriented, and there were no signs of delusions or hallucinations (he denied suicidal and homicidal ideation). Further, on psychological testing in March 2017, his depressive symptoms were in the moderate range of severity. Significantly also, he was not shown to have been incapable of managing his own financial matters, and although he had anger management difficulties, at no time was he considered by an examining or treating provider to pose a persistent threat of danger or injury to himself or others. He has been shown to have participated in recreational and leisure activities. As noted in various treatment records in 2017, he took vacation trips with his girlfriend, enjoyed holidays with family, and occupied himself with fishing and cooking (all functioning inconsistent with disability with total occupational and total social impairment). The Veteran may have experienced some symptoms contemplated by a 100 percent rating, but they are not well-indicated. For example, he may have at times engaged in grossly inappropriate behavior, but even this symptom is difficult to specifically identify in the records, unless his use of alcohol to excess despite contraindications based on taking medication in treatment of depression, sleep problems, and pain, is so found. Regardless, the overall evidence does not demonstrate the level of severity of impairment associated with a 100 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. Further, while he has been granted a TDIU rating (as will be discussed in detail below), he was not shown to have had total social impairment. VA treatment records show he continued to live with his long-time girlfriend (albeit with asserted "enduring relationship problems"), and he was noted to maintain strong ties with family members, particularly children and grandchildren. Even if his "social circle" was of modest size (e.g., the March 2017 VA examiner found his social functioning to be "very limited"), it was meaningful for him. In short, it is not reasonable to conclude he had complete social impairment. A year earlier, at the June 2016 hearing, the Veteran described having a lot of depression, verbal assaults, physical fights, short-term memory loss, non-social conduct and isolation, irritability and argumentativeness (with authorities), and lack of motivation. He said he had no close friends but had extensive family that he saw. He indicated he had suicidal ideation set off by feelings of worthlessness about 3-4 times in the past year and a half, as well as flashbacks. Assuming this self-reflection was accurate a year later during the period under consideration (with the exception of suicidal ideation, which he denied in treatment records and therefore it cannot be seen as persistent), such symptoms are much more comparable to the symptoms contemplated for a 70 percent rating (e.g., impaired impulse control, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships) than a 100 percent rating. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. The criteria for a 100 percent or higher rating are not met and the appeal in this matter must be denied. 2. Entitlement to a TDIU rating prior to December 14, 2017 A TDIU rating may be assigned where the schedular rating is less than total, when it is found that the veteran is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability rated 60 percent or more, or as a result of two or more disabilities, provided at least one is rated 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or higher. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). From July 20, 2017 to December 14, 2017, the Veteran's service-connected disabilities included: PTSD, [rated] 70 percent; obstructive sleep apnea, 50 percent; fibromyalgia, 40 percent; chronic fatigue syndrome, 20 percent; pseudofolliculitis barbae, 0 percent; and erectile dysfunction, 0 percent. The combined rating was 90 percent. In November 2018, the Veteran filed VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, indicating that he became too disabled to work on July 20, 2017, when last worked full-time, due to chronic fatigue, PTSD, anxiety, and fibromyalgia. He indicated he worked in a warehouse for the six years prior to his last day at work and lost 9-10 days a month due to the increasing severity of his ailments (and the "[l]ong list of medications" he took that affected him at work). He had not tried to obtain employment since he became too disabled to work. Regarding education, he completed high school and had no additional training or education either before or since he became too disabled to work. After consideration of the lay and medical evidence, the Board concludes that for the period at issue, the evidence is in equipoise as to whether the Veteran has been unable to maintain substantially gainful employment due to a combination of his service-connected disabilities from July 21, 2017 (the day following the dated when he was last employed full-time) to December 14, 2017 (from when a TDIU rating is already assigned). At the June 2016 Board hearing, the Veteran described how his service-connected disabilities, particularly his mental health disability, impacted his industrial functioning. For example, he spoke about how difficult it was to work with co-workers and how he did not "get along with a lot of folks." He noted verbal altercations at work and stated that colleagues had told him he was "hotheaded." He noted that he was fired from a warehouse job [in 2010] because he was leaving early to attend medical appointments. Records from the Social Security Administration (SSA) show that the Veteran was awarded disability benefits, with an onset date of July 20, 2017, due to primarily unspecified arthropathies and secondarily fibromyalgia. In his application, he asserted his disabilities consisted of chronic fatigue syndrome, chronic pain, gout, PTSD, depression, and anxiety. His work history (since 2000) consisted of two different warehouse jobs, whereby he moved products, picked up cases, and loaded/unloaded trucks; he was not a supervisor or lead worker. After consultative examinations to determine the current severity of his impairments in October 2017 and November 2017, it was found that the Veteran had severe impairment in dysfunction of his major joints, fibromyalgia, spine disorders, anxiety and obsessive-compulsive disorders, depressive disorders, and trauma/stressor-related disorders. In determining residual functional capacity, the Veteran's exertional limitations included occasionally lifting and/or carrying 20 pounds, standing and/or walking for four hours, and sitting for a total of six hours in a workday. Moreover, he could occasionally climb ramps/stairs, never climb ladders, occasionally balance/stoop/kneel/and crouch, and never crawl. One examiner found the severity of the symptoms and alleged effects on function of the Veteran's disabilities were not entirely consistent with the total medical and non-medical evidence, including statements by the Veteran, as some symptoms appeared to be "disproportionate to the severity and duration that would be expected, based on the [Veteran's] medically determinable impairment(s)." It was determined by one evaluator that he did not have the residual functional capacity to perform his past relevant work as a warehouseman, that his highest skill level from past work was semi-skilled, and that he was limited to unskilled work because of his impairments. VA records show a disability picture somewhat at odds with the Veteran's claims of unemployability. For example, on a May 2017 mental health note, the assessment included job and relationship dissatisfaction. The note further indicates that he hated his job but had not looked for other work, and that he applied for an early retirement offer as well as claims for increased ratings (he indicated that if his [VA disability] rating was increased to 100 percent, he would receive nearly as much as he earned from working but without all the "hassles"). In July 2017, a mental health note indicates that the Veteran was in a fairly upbeat mood that day and reported that after years of ambivalence he finally decided to quit his job and give a 2-week notice; the deciding factor was reportedly reassurance from his long-time girlfriend that she would support him financially until he could find other work. Further, he could not "wait to be done with his miserable job and commute" and hoped to take the rest of the summer off to pursue his passion of fishing before looking for part-time work as a short order cook (cooking was another passion). It was also noted he was working on his anger management so that he did not "wind up in jail." An August 2017 mental health note indicates that the Veteran decided to resign from his job after careful consideration that it was causing too much stress, and that he was taking some time off before deciding to search for another job. Another August 2017 note, as also one in October 2017, indicates the Veteran quit his "dead end job" due to high dissatisfaction with the unfulfilling work and miserable commute. On a November 2017 mental health note, he was thinking of getting another job and was beginning a search; he expressed a wish to be self-employed because he disliked long commutes and dealing with too many people. A January 2018 mental health note indicates he reported much less anger and depression since quitting his job and now considered himself "retired." He had no interest in returning to work, was re-evaluating his priorities, and just wanted to relax and enjoy himself. A February 2019 VA psychiatric examination report indicates that the Veteran reported he left his last job on his own volition due to difficulty managing stress. The Board finds that the evidence reasonably shows that the Veteran was not capable of maintaining substantially gainful employment from July 21, 2017 (the day following the date on which the Veteran reported he last worked full-time) to December 14, 2017, especially considering his level of education, prior work experience, and training. On the one hand, contemporaneous VA outpatient treatment records appear to show that he stopped working on July 20, 2017 (that being his last day of work) by choice because he disliked his job and commute. From his statements documented in the outpatient records at that time, it appears that he just preferred to not work because of stress. Further, after leaving his job, he initially expressed an intent to find another job. Thus, while VA treatment records appear to reflect that he had some difficulty maintaining full-time employment, they do not show he was unable to keep his job. On the other hand, the Veteran has a high school education and no specialized training in a profession. He has apparently been engaged in a narrow category of industrial/manual labor-type (unskilled) employment for a long time (at least since 2000) as a warehouseman before stopping work in July 2017. His assertions that he was no longer able to continue working in July 2017 due to his service-related symptoms is supported by SSA evaluators, who assessed his residual physical and mental capacities in the months after July 2017 and ultimately found him to be disabled. Although there was a question raised as to inconsistency of the severity of symptoms and the purported functional effects with the medical and non-medical evidence, it was determined he did not have the functional capacity to perform his previous work as a warehouseman and was limited to unskilled work due to his (primarily physical) impairments that included his service-connected disabilities. Thus, there is evidence both in favor and against the Veteran's TDIU claim, and such evidence involves his physical and mental disabilities, in combination. All things considered, and mindful of affording the Veteran the benefit of the doubt where there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, including the severity of service-connected disabilities (see 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3), the Board finds that from the earlier effective date of July 21, 2017 his service-connected disabilities precluded him from maintaining the type of work for which he has experience or for which he could feasibly be trained. Therefore, a TDIU rating is warranted from the July 21, 2017 earlier effective date. George R. Senyk Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debbie Breitbeil, 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.