Citation Nr: 21065696 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 18-05 932 DATE: October 27, 2021 ORDER Service connection for dysthymia/depressive disorder and cocaine dependency disorder, as secondary to the service-connected posttraumatic stress disorder (PTSD) is granted. A rating of 70 percent, but no higher, for the PTSD, dysthymia/depressive disorder, and cocaine dependency disorder, is granted. Entitlement to a temporary total rating for hospitalization for treatment for a service-connected disability from October 25, 2011 and January 20, 2012 is granted. A total disability rating for individual unemployability (TDIU) is granted. REMANDED Entitlement to a rating higher than 70 percent for the PTSD with dysthymia disorder is remanded. FINDINGS OF FACT 1. Resolving any reasonable doubt in the Veteran's favor, the dysthymia/depressive disorders and cocaine dependency disorder is proximately due to the service-connected PTSD. 2. During the entire period on appeal, the Veteran's acquired psychiatric disabilities more nearly manifested as occupational and social impairment causing deficiencies in most areas. 3. The Veteran was hospitalized in excess of 21 days at the Milwaukee Domiciliary between October 25, 2011 and January 20, 2012 for the treatment of a psychiatric disability and other conditions. No other periods of inpatient treatment were longer than 21 days. 4. Excluding the period of temporary total disability between October 25, 2011 and January 20, 2012, the Veteran's service-connected psychiatric disabilities and concussion with residuals prevented him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for dysthymia/depression and cocaine dependence are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for a 70 percent rating for the acquired psychiatric disabilities have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411. 3. The criteria for entitlement to a temporary total evaluation for hospitalization for treatment of a service-connected disability under 38 C.F.R. § 4.29 from October 25, 2011 to January 20, 2012 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.29. 4. 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, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1966 to December 1968 with combat service in Vietnam. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a May 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2020, the Veteran testified before the undersigned Veterans Law Judge via virtual hearing. A copy of the hearing transcript is of record and has been reviewed. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). 1. Service connection for dysthymia/depressive disorder and cocaine dependency disorder, as secondary to the service-connected PTSD, is granted; and 2. A rating of 70 percent, but no higher, for the acquired psychiatric disorders is granted. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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 rating 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 disabilities. 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. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran is currently assigned a 50 percent rating for the service-connected psychiatric disabilities. The Veteran asserts that his psychiatric disabilities were more severe than the currently assigned rating. 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). A noncompensable 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. As an initial matter, the Veteran has been awarded service connection for PTSD. VA treatment records, April 2013 VA examination, September 2013 private Disability Benefit Questionnaire (DBQ), November 2017 VA examination, and the Veteran's lay statements include evidence that weighs both in favor and against the claim for a rating higher than 50 percent. These records show that the Veteran's PTSD was manifested by some symptoms associated with a rating of 50 percent or lower, such as suspiciousness, depression, anxiety, chronic sleep impairment, disturbances of mood and motivation, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. The evidence also shows that the Veteran had symptoms associated with a 70 percent rating, including the inability to maintain effective relationships, intermittent suicidal ideations, near-continuous depression affecting the ability to function independently, appropriately, and effectively, and one objectively documented incident of personal hygiene neglect. The Veteran also exhibited symptoms that are not associated with a particular rating, to include mild cognitive impairment, visual-spatial disorientation, nightmares, intrusive thoughts, chronic insomnia, hypervigilance, exaggerated startle response, flashbacks, hopelessness, difficulty concentrating, tearfulness, excessive anger, inconsistent appetite, isolation, guilt, shame, anhedonia, avoidance of people, places, events, avoidance of internal and external cues of the trauma, and physiological reactivity to cues that reminded him of the trauma. An April 2013 VA examiner, a physician, concluded that the Veteran's PTSD more nearly manifested as occupational and social impairment with reduced reliability and productivity, consistent with a 50 percent rating, with symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, disturbance of motivation or mood, and difficulty establishing and maintaining effective work and social relationships. On a September 2013 private DBQ, the Veteran's long-term treating VA psychiatrist indicated that the Veteran's PTSD more nearly approximated occupational and social impairment with deficiencies in most areas. This VA clinician treated the Veteran since 2008 and reviewed the Veteran's VA treatment records. The clinician diagnosed the Veteran with PTSD, depressive disorder, not otherwise specified, and cocaine dependency. The examiner indicated that all the diagnosed psychiatric disorders presented with depression; therefore, the symptoms of each psychiatric disorder could not be differentiated. The same VA psychiatrist wrote a November 2013 letter which reported the Veteran was being treated for PTSD and depression, and he remained "significantly symptomatic." In August 2014, the Veteran's treating VA psychiatrist wrote that, throughout his life, the Veteran had residuals of PTSD, including sleeping with a gun, mood swings, insomnia due to recurrent nightmares, severe difficulty maintaining relationships with family, difficulty maintaining jobs, disruptive flashbacks, difficulty maintaining stable living situations with periods of homelessness, and periods of severe depression with two previous suicide attempts. A November 2017 VA examiner, a physician, diagnosed the Veteran with PTSD and persistent depressive disorder (dysthymia). The examiner indicated that it was not possible to differentiate the symptoms of the two disorders. Furthermore, the examiner concluded that the Veteran's PTSD and persistent depressive disorder manifested as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication, consistent with a rating less than 50 percent. Nevertheless, the physician indicated that the symptoms to support the diagnostic criteria for PTSD had worsened as the physician noted he exhibited more symptoms than had been documented in the previous VA examination. The Veteran's PTSD and dysthymia manifested as symptoms of depressed mood, suspiciousness, chronic sleep impairment, flattened affect, and disturbances of motivation and mood. The Veteran also completed a Beck Inventory II, which indicated the Veteran had severe dysthymia. This level of depression resulted in anhedonia, low self-esteem, restlessness, agitation, tiredness, fatigue, changes in appetite, and changes in sleep pattern. In March 2018 VA treatment records, the Veteran's treating VA psychologist noted that the Veteran requested a letter in support of his claim. The clinician indicated that she rarely became involved with compensation claims, but in this case, she believed the Veteran "clearly suffers from chronic PTSD and depression, which have contributed to a long history of [substance abuse disorder], suicide attempt, and losing his family, among other problems..." The Veteran testified before the Board in August 2020. The Veteran had chronic headaches, nightmares, worsening memory, difficulty gathering his thoughts, and suicidal and homicidal thoughts. The Veteran had to end the hearing prematurely due to the stress of discussing his symptoms and experiences and the inability to gather his thoughts. A September 2020 letter indicated the Veteran experienced recurrent and unwanted distressing memories of the trauma, flashbacks, nightmares, severe emotional distress and physical reactions to things that reminded him of the trauma, avoided thinking and talking about the trauma, avoided places, activities, and people that reminded him of the trauma, persistent negative thoughts of himself and others, feelings of hopelessness about his future, difficulty with memory, difficulty maintaining close relationships, feeling detached from family and friends, lack of interest in actives he once enjoyed, difficulty experiencing positive emotions, feeling numb, difficulty sleeping, difficulty concentrating, irritability, angry outbursts, aggressive behavior, overwhelming guilt and shame, suicidal and homicidal ideations, and lack of personal relationships. As a preliminary matter, service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). For claims filed after October 31, 1990, service connection on a direct incurrence basis cannot be granted for disabilities resulting from abuse of alcohol or drugs. See 38 U.S.C. §§ 105, 1110, 1131; 38 C.F.R. §§ 3.1 (n), 3.301. Further, in Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that compensation could not be awarded pursuant to 38 U.S.C. § 1131 and 38 C.F.R. § 105(a) either for a primary alcohol/drug abuse disability incurred during service or for any secondary disability that resulted from primary alcohol/drug abuse during service. Id. at 1376. However, the Federal Circuit further held that service connection for compensation can be awarded for an alcohol/drug abuse disability acquired as secondary to, or as a symptom of a non-willful misconduct, service-connected disability. In further clarifying this, the Federal Circuit explained that veterans may recover only if they can adequately establish that their alcohol or drug abuse disability is secondary to or is caused by their primary service-connected disorder. Id. at 1381. Here, the Veteran has been diagnosed with depressive disorder (dysthymia) and cocaine dependency during the appellate period. See September 2013 DBQ and November 2017 VA examination. Both the September 2013 clinician and the November 2017 VA examiner determined that the symptoms of these disorders could not be differentiated. When it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, 38 C.F.R. § 3.102 requires the Board to attribute all signs and symptoms to the service-connected disability. Mittleider v. West, 11 Vet. App. 181 (1998). Furthermore, in August 2014 and March 2018 the Veteran's long-term treating VA psychiatrist and VA psychologist submitted opinions that the PTSD resulted in intermittent drug addiction and severe depression. After resolving any reasonable doubt in favor of the Veteran, service connection is warranted for dysthymia/depressive disorder and cocaine dependency as secondary to the service-connected PTSD with memory loss disability. Turning to the claim for a rating higher than 50 percent for the psychiatric disabilities, after a review of the evidence, both lay and medical, the Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates a 70 percent rating. The Veteran experienced occupational and social impairment with deficiencies in most areas. Mental status examinations in the VA treatment records show that the Veteran was generally casually, neatly, and appropriately dressed. Nevertheless, on one occasion, the Veteran was dressed in soiled clothing and exhibited poor hygiene. Throughout the appellate period, his mood was persistently depressed with consistent affect. His thought process remained logical and focused. He also reported intermittent suicidal ideations throughout the appellate period. The Veteran had a plan to commit suicide by jumping on the "El tracks" in October 2011 and was subsequently hospitalized for treatment at the Jesse Brown VAMC. The Board finds the severity, frequency, and duration of the Veteran's psychiatric symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are more severe, more frequent, and longer in duration than those contemplated by a 50 percent rating. See 38 C.F.R. § 4.126. The Board notes that the Veteran expressed intermittent suicidal ideation, which could be similar to persistent danger of self-harm contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Veteran more frequently denied thoughts, intent, or a plan involving self-harm in existing VA treatment records and during the April 2013 and November 2017 VA examinations. Thus, the suicidal ideations have not risen to the level of persistent danger of self-harm. Nevertheless, the claim is being remanded to afford the Veteran an additional VA examination to determine whether a rating higher than 70 percent for the service-connected psychiatric disability is warranted. In short, after resolving any reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that the service-connected psychiatric disability more nearly manifested as occupational and social impairment with deficiencies in most areas during the entire period on appeal. Thus, a 70 percent rating is granted. 2. Entitlement to a temporary total rating from October 25, 2011 and January 20, 2012 is granted. The Veteran contends a temporary total disability rating was warranted for an in-patient admission for psychiatric and drug rehabilitation treatment at the Milwaukee domiciliary between October 25m 2011 and January 20, 2012. See December 2011 claim, January 2012 statement, August 2020 hearing transcript. A temporary total disability rating will be assigned when it is established that one or more service-connected disabilities has required hospital treatment in a VA or an approved hospital for a period in excess of 21 days or hospital observation at VA expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. Domiciliary care is defined as either a temporary home to a veteran, embracing the furnishing of shelter, food, clothing, and other comforts of home, including necessary medical services; or, a day hospital program consisting of intensive supervised rehabilitation and treatment provided in a therapeutic residential setting for residents with mental health or substance abuse disorders, and co-occurring medical or psychosocial needs such as homelessness and unemployment. 38 C.F.R. § 17.30(b)(1). As the definition of domiciliary care is considered a day hospital program under the second definition above, a veteran would be eligible for benefits under 38 C.F.R. § 4.29 if living in a domiciliary program for purposes of treating a service-connected condition. The Veteran has been service connected for PTSD, to include memory loss and residual symptoms of depression, since January 5, 2011. The question in this case is whether the Veteran's admission to the Milwaukee domiciliary program was required to treat a service-connected disability. As an initial matter, the Veteran was admitted to the Milwaukee domiciliary on October 25, 2011 and was discharged on January 20, 2012, which is a period longer than 21 days. The October 25, 2011 mental health intake note found that the Veteran did "not need hospitalization for acute medical or psychiatric problems at this time and is appropriate for residential treatment." The plan was to admit him to the domiciliary program. However, the January 20, 2012 discharge summary shows the Veteran was admitted to the Milwaukee domiciliary program for treatment of depression and addiction, and he was discharged for completion of the program. The VA treatment records indicate that the VA domiciliary care focused on both PTSD, anger management, and substance abuse. After resolving all reasonable doubt in favor of the Veteran, and given the above definition of domiciliary care, and the VA treatment records indicating that the Veteran's hospital program was necessary for treatment of the service-connected psychiatric and additional disabilities, the Board finds that the October 25, 2011 to January 20, 2012 domiciliary stay qualifies as hospital treatment in excess of 21 days under 38 C.F.R. § 4.29. As such, a temporary total rating for service-connected PTSD, depression, and cocaine dependency is warranted from October 25, 2011 to January 20, 2012. Resolving all reasonable doubt in the Veteran's favor, the claim is granted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Board notes the Veteran had additional inpatient treatment for the service-connected psychiatric disabilities in 2011. Nevertheless, none of these periods were in excess of 21 days and do not qualify for temporary total disability under 38 C.F.R. § 4.29. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. A total disability rating for individual unemployability (TDIU) The Veteran contends that his service-connected psychiatric disabilities and concussion residuals prevent him from securing and following substantially gainful employment. See August 2020 hearing transcript. A TDIU may be assigned, where the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 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. Id. For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3)disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a); see Moody v. Wilkie, 30 Vet. App. 329, 339 (2018) (combining disabilities as "one disability" to meet the rating threshold of § 4.16(a) requires the use of the combined rating table). The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component refers to an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a veteran's ability to secure and follow such employment. Id. Attention should be given to the veteran's history, education, skills, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, as well as auditory and visual limitations); and whether the veteran has the mental ability to perform the activities required by the occupation at issue (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. An award of TDIU is an individualized determination, specific to a veteran's particular circumstances, e.g., their history, education, skills, and training. See Todd v. McDonald, 27 Vet. App. 79, 85 (2014). It does not require a showing of 100 percent unemployability. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). The ultimate question is whether they can perform the physical and mental acts required by employment, not whether they can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has the following service-connected disabilities: PTSD with dysthymia/depression, cocaine dependency in remission, and memory loss (now rated 70 percent, effective January 5, 2011); deviated naval septum and allergic rhinitis (rated as noncompensable effective to August 9, 2017 and 30 percent thereafter); nose and right eye scar (rated as 10 percent disabling effective December 11, 1968); left eye scar (rated as 10 percent disabling, effective May 19, 2006); and history of cerebral concussion with no traumatic brain injury (TBI) (rated as 10 percent disabling, effective October 10, 2008). Based on the forgoing, the Veteran has at least one disability rated at 40 percent or more and sufficient additional disabilities to bring the combined rating to 70 percent or more for the entire period on appeal. Accordingly, the Board may consider the claim for a TDIU on a schedular basis. 38 C.F.R. § 4.16(a). For the following reasons, the Board finds that a TDIU is warranted. The Veteran earned a bachelor's degree in business management and accounting, and he worked in accounting and finance for the railroad for 27 years. He retired in 1988. See January 2021 VA treatment records. April 2002 VA treatment records noted that he was employed as a department store sales associate approximately five years earlier, and before that job, he worked as a bookkeeper and accountant. More recent VA treatment records note the Veteran was "no longer working part time" but did not indicate how he was employed or include when the employment started or ended. On the March 2017 VA 21-8940, the Veteran indicated he worked for the railroad in accounting and logistics from 1971 to 1988. He indicated he left this job due to his service-connected disabilities, and he received disability retirement benefits. He also applied to work at Marshall Fields as an associate in casual wear in October 1995. The Veteran initially selected that he completed three years of college, but then marked through that selection, and indicated that he only had a high school degree. In a February 2018 VA examination for the concussion residuals, the examiner indicated there was objective evidence of moderate impairment of memory, attention, concentration, or executive dysfunction. Furthermore, the examiner found that the Veteran's visual spatial disorientation impairment was moderately severe. The Veteran frequently forgot where he was going, even for familiar trips such as to the VAMC for treatment. He required both a map and a relative to help him get to familiar places on public transit. In the August 2020 hearing, the Veteran was so upset when discussing his symptoms, his representative requested to end the hearing and permission to submit a written statement of his symptoms instead. Before the hearing ended, the Veteran indicated that he had difficulty gathering and communicating his thoughts. The representative also noted the Veteran was having difficulty explaining his PTSD symptoms. A September 2020 letter indicated the Veteran experienced recurrent and unwanted distressing memories of the trauma, flashbacks, nightmares, severe emotional distress and physical reactions to things that reminded him of the trauma, avoided thinking and talking about the trauma, avoided places, activities, and people that reminded him of the trauma, persistent negative thoughts of himself and others, which included feelings of hopelessness about his future, difficulty with memory, difficulty maintaining close relationships, feeling detached from family and friends, lack of interest in actives he once enjoyed, difficulty experiencing positive emotions, feeling numb, difficulty sleeping, difficulty concentrating, irritability, angry outburst, aggressive behavior, overwhelming guilt and shame, suicidal and homicidal ideations, and lack of personal relationships. After reviewing the evidence, both lay and medical, the Board finds the Veteran's ability to secure and follow a substantially gainful occupation is impacted by the mental effects of the psychiatric and concussion residuals. The Veteran's psychiatric disability and concussion residuals have resulted in diminished motivation and mood, chronic sleep impairments, memory loss, cognitive impairment, visuospatial impairments, inability to establish and maintain effective work relationships, difficulty with concentration, moderate impairment of attention and executive dysfunction, intermittent suicidal and homicidal ideations, and a history of substance abuse. As to physical labor, the Veteran has no history of experience in physical or manual labor. He has never worked as a skilled laborer, such as a plumber or electrician. His education and prior work history required detail-oriented, organized tasks related to accounting, finance, and managing others that required focus and concentration. He also has previous work experience in middle management, but his inability to establish or maintain effective work relationships would make management of other people nearly impossible. His service-connected psychiatric disabilities and concussion residuals, specifically the moderate short term memory impairment, difficulty concentrating, impaired attention, residuals of daytime sleepiness related to the chronic sleep impairment, and the inability to maintain effective work relationship, would make maintaining this type of work unlikely. Given the evidence, excluding the period of temporary total disability from October 25, 2011 to January 20, 2012, the Veteran's service-connected psychiatric and concussion residual disabilities preclude him from securing and following substantially gainful employment consistent with his education, skills, training, and work history during the entire period on appeal. For the entire period on appeal, a TDIU is granted. REASONS FOR REMAND 1. Entitlement to a rating higher than 70 percent for PTSD, dysthymia/depressive disorder, and cocaine dependency disorder in remission, is remanded. The Veteran and his representative have asserted that the Veteran's service-connected PTSD disability worsened since the Veteran's most recent November 2017 VA examination. See September 2020 statement. The fact that a VA examination is almost four years old is not a valid basis, unto itself, to provide the Veteran with another VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-83 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). However, in this case, the Veteran and his representative's asserted that the psychiatric disability has worsened after the most recent VA examination; therefore, a new VA examination is needed to assist in determining the current severity of the Veteran's service-connected PTSD disability. Snuffer, 10 Vet. App. at 400. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims file. 2. Schedule the Veteran for a VA psychiatric examination with an appropriate clinician to determine the nature and severity of the service-connected psychiatric disabilities. 3. Readjudicate the remanded claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Harper, 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.