Citation Nr: 21066113 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 09-34 839 DATE: October 28, 2021 ORDER Prior to August 8, 2016, an initial disability rating of 70 percent, but no higher, for service-connected posttraumatic stress disorder is granted. From August 8, 2016, an increased disability rating in excess of 70 percent for service-connected posttraumatic stress disorder is denied. An earlier effective date of November 22, 2006, for a total disability rating based on individual unemployability is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, during the entire claim period, the severity, frequency, and duration of his mental health symptoms resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. During the entire claim period, the severity, frequency, and duration of the Veteran's mental health symptoms did not result in total occupational and social impairment. 3. From November 22, 2006, the Veteran's service-connected posttraumatic stress disorder symptoms resulted in his inability to secure and maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating of 70 percent for posttraumatic stress disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. During the entire claim period, the criteria for an increased disability rating in excess of 70 percent for posttraumatic stress disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 3. From November 22, 2006, the criteria for entitlement to a total disability rating based on individual unemployability have been met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.340, 3.400, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1966 until his honorable discharge in June 1969, with service in the Republic of Vietnam. This appeal has been advanced on the Board of Veterans' Appeals' (Board) docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c)(d). This case comes before the Board on appeal from a March 2008 decision by the North Little Rock, Regional Office of the United States Department of Veterans Affairs (VA), which granted service connection for posttraumatic stress disorder (PTSD) and assigned an initial disability rating of 30 percent effective November 22, 2006. In an August 2009 rating decision, the VA Regional Office assigned the Veteran an initial disability rating of 50 percent effective November 22, 2006. In April 2011, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge, seeking a 100 percent disability rating. This case a long procedural history, with multiple remands by the Board to the VA Regional Office and multiple remands from the United States Court of Appeals for Veterans Claims (Court) back to the Board. At this point, it suffices to say that the VA Regional Office awarded the Veteran an increased disability rating of 70 percent as of August 18, 2016, and it continued the initial 50 percent disability prior to August 18, 2016. The VA Regional Office also granted the Veteran a total disability rating based on individual unemployability (TDIU) as of August 18, 2016. In January 2021, the Board issued a decision denying an increased disability rating in excess of 50 percent prior to August 18, 2016, and in excess of 70 percent thereafter. The Board also denied entitlement to an earlier effective date for the award of TDIU benefits. The Veteran appealed the Board's January 2021 decision to the Court. At the Court, the parties entered a Joint Motion to Remand, stating that the Board did not address favorable evidence to the Veteran and failed to offer valid reasons or bases for denying an earlier effective date for the award of TDIU benefits. Consequently, the Court entered a July 2021 order vacating the Board's decision and remanding the case back to the Board for readjudication. 1. Prior to August 8, 2016, an initial disability rating of 70 percent, but no higher, for service-connected posttraumatic stress disorder is granted. 2. From August 8, 2016, an increased disability rating in excess of 70 percent for service-connected posttraumatic stress disorder is denied. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence when rating disabilities. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 C.F.R. § 4.3. 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). An initial rating is one assigned at the time service-connection is granted. Generally, the effective date of an initial rating is the date of receipt of the claim or request or the date entitlement arose, whichever is later. 38 U.S.C.§ 5110(a); 38 C.F.R. § 3.400(o)(1); see Sutton v. Nicholson, 20 Vet. App. 419, 422 (2006). When an initial rating decision is on appeal, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at those times and should be the evidence used to decide whether an original rating was erroneous. Fenderson v. West, 12 Vet. App. 119, 126 (1999). A claim for an increased rating is a new, distinct claim. See Suttman v. Brown, 5 Vet. App. 127, 136 (1993) (a claim for an increase is "based upon facts different from the prior claim"). An increased disability rating is generally assigned based on a showing that a service-connected disability has worsened. The Board is to consider each disability in relation to the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999); 38 C.F.R. § 4.1. The Board must also determine if it is factually ascertainable that the disability worsened within one year preceding the filing of the claim because an earlier effective date for an increased disability rating may be warranted. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). Separate ratings can be assigned for separate periods of time based on the facts founda practice known as "staged" ratings. Id. at 126. A staged rating is a rating that looks backwards and retroactively assigns specific ratings to discrete periods. See Reizenstein v. Shinseki, 583 F.3d 1331, 1337 (Fed. Cir. 2009). This practice accounts "for the possible dynamic nature of a disability while the claim works its way through the adjudication process." O'Connell v. Nicholson, 21 Vet. App. 89, 93 (2007); see also 38 C.F.R. § 4.1. The effective date for a staged rating is when it is factually ascertainable that a particular rating is warranted. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). In cases where staged ratings are appropriate, it is necessary to consider all "the evidence of record from the time of the veteran's application." Fenderson, 12 Vet. App. at 127. The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Diagnostic codes are assigned to individual disabilities. Diagnostic codes provide rating criteria specific to a particular disability. If two diagnostic codes are applicable to the same disability, the diagnostic code that allows for the higher disability rating applies. 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Id. Rating Criteria PTSD Under the General Formula for Mental Disorders (General Formula), 38 C.F.R. § 4.130, 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). The symptoms listed in the VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, which would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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, 11418 (Fed. Cir. 2013). The General Formula, 38 C.F.R. § 4.130, DC 9411, provides, in pertinent part, as follows: Rating (%) 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; memory loss for names of close relatives, own occupation, or own name. 100 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 worklike setting); inability to establish and maintain effective relationships. 70 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 50 38 C.F.R. § 4.130, Diagnostic Code 9411 does provide for ratings lower than 50 percent. In this case, however, the Veteran received an initial disability rating of 50 percent. Thus, an analysis of the ratings lower than 50 percent is unwarranted, absent legal and factual bases to issue a reduction in the Veteran's current rating. See 38 C.F.R. § 3.344. Considerations in rating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. Id. Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The United States Court of Appeals for the Federal Circuit held that evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Vazquez-Claudio, 713 F.3d at 11617. Relevant to this case, for all appeals certified to the Board after August 4, 2014, VA moved from using the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) to using the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). See 80 Fed. Reg. 14,308 (Mar. 19, 2015). A key difference between the DSM-IV and the DSM-5 is that the newer edition no longer employs Global Assessment Functioning (GAF) scores to assess the effect of a mental disorder on a person suffering from such a condition. Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). GAF scores are no longer considered an acceptable metric. See id. But for cases certified to the Board prior to August 4, 2014, GAF scores remain a valid consideration. Id. Here, the Veteran's appeal was certified to the Board in October 2010. Therefore, the GAF scores remain relevant evidence to consider in this case. See Cline v. Shinseki, 26 Vet. App. 18, 28 (2012) (GAF scores "are not dispositive of the proper level of disability.") Analysis Because this case has been ongoing since 2006, there is a substantial amount of lay and medical evidence within the Veteran's claims file. The Board finds that it is most logical to address the Veteran's PTSD symptoms as demonstrated by all of the evidence and then offer an analysis as to the appropriate rating. It would be unduly burdensome to identify each and every individual symptom and time of occurrence. Therefore, the Board will address the Veteran's symptoms collectively under appropriate headings. This is not meant to capture every individual symptom but rather the most relevant and significant symptoms in the Veteran's favor. Gonzales, 218 F.3d at 1381. PTSD Symptoms Suicidal/Homicidal Ideations First, the Board observes that many of the Veteran's early mental health treatment and examinations, those prior to 2014, did not indicate that he experienced suicidal or homicidal ideations. But, during a May 2009 VA examination, the Veteran reported "hearing dead bodies demanding that he come with them or follow them." In February 2014, the Veteran reported to his VA psychiatrist that he saw "a spirit" that "looked like a lion," several times a week. He would hear a voice telling him to follow it, and it wanted him to kill himself. He continued to report this experience to his VA psychiatrist in April and June 2014. In September 2015, he reported he had experienced a long history of suicidal ideations. While the Veteran's mental health and general medical records do not document a history of suicidal ideations, the Board finds this is not dispositive. In a correspondence dated January 3, 2013, from the Veteran, he reported that expressing his past suicidal ideations at every turn when questioned was too difficult for him to do. He expressed his feelings of guilt, shame, and embarrassment in having to tell others, including medical professionals, about his ideations. Hence, he kept them too himself. At his April 2011 Board hearing, he expressed similar thoughts. The Board finds the Veteran's candidness credible. This is a topic of much contention that may be difficult for any reasonable person to discuss. The Board finds the Veteran's statements probative and believes that he did experience suicidal ideations during the claim period beyond what is documented within his medical records. Beginning in September 2015, the Veteran expressed homicidal ideations to his VA psychiatrist, particularly as it related to VA medical professionals who have assessed him. He cited a desire to "throw[] a Molotov cocktail at their house." In October 2016, he again cited homicidal ideations. He dreamed about killing certain groups of people, without having any intent to do so. His VA psychiatrist documented his belief that the Veteran was not forthcoming about particular symptoms or traumas and did not press the Veteran for further information. The Board finds this particular observation by VA psychiatrist's highly relevant because it lends further credibility to the Veteran's own statement that he did not want to express his prior suicidal ideations for various reasons. In sum, the Board finds that the evidence, lay and medical, demonstrates that the Veteran experienced suicidal and homicidal ideations during the claim period, even though he had no intention of acting on them. Chronic Sleep Disturbances The Veteran's medical records document persistent sleep disturbances associated with his PTSD. He endorsed nightmares related of his service in Vietnam. He consistently reported receiving, on average, two to three hours of sleep per night through the claim period. His constant thoughts and dreams of dead bodies associated with his service in Vietnam prevented him from obtaining restful sleep. At his April 2011 Board hearing, he testified that he experienced nightmares six to seven times a week. He had to begin sleeping in a separate bed from his wife due to his chronic sleep disturbances. In turn, his chronic sleep disturbances led to decreased energy and chronic fatigue during the claim period. The Veteran's chronic sleep disturbances are well-documented throughout his medical records and mental health evaluations. The Board finds his statements highly credible and probative. Hallucinations/Delusions As previously discussed, the Veteran has consistently reported experiencing symptoms that appear equivalent to hallucinations or delusions. During a January 2008 VA examination, he reported "hearing and seeing things." He reported similar hallucinations during January 2009 VA examination. During his April 2011 Board hearing, he testified that he saw experiences from Vietnam. These hallucinations have persisted and have apparently increased in severity. The Veteran's sister submitted a statement dated September 4, 2012, in which she explained that the Veteran withdraws himself from family functions and chooses to sit by himself. She has observed him speaking to himself or having a conversation with someone who is not there. In September 2013, the Veteran reported to his VA psychiatrist that he saw "spirits of the people from Vietnam coming after him." Beginning in 2014, and continuing thereafter, his hallucinations were manifesting as potential suicidal ideations as explained above. Anxiety and Depression and General Mood Through the claim period the Veteran has reported anxiety and depression. He has primarily identified stimuli including politics, death, and war as triggers for his anxiety. During an October 2006 private psychological evaluation, he reported "acute and intense" symptoms of anxiety, nausea, and foreboding, which were precipitated by images of injured, dead, and dying soldiers he viewed in the news and in newspapers. He described a generalized sense of dread. He made conscious efforts to avoid triggering stimuli, to include funerals and any circumstance involving death. He was unable to engage in routine conversations with others due to his fear of discussing triggering stimuli. He felt constantly "on edge" and irritable and experienced chronic tension. During a January 2008 VA examination, the examiner observed that the Veteran displayed general dysphoria (a state of generalized unhappiness, restlessness, dissatisfaction, or frustration). During a January 2009 VA examination he displayed general sadness and anxiety. An August 2012 VA examiner endorsed that the Veteran had depressed mood and disturbances of motivation and mood. The Veteran's spouse reported that he was irritable, which the Veteran also reported. In September 2012, he reported feeling depressed nearly every day. In a December 2013 correspondence, the Veteran reported he was unable to handle his anxiety. In September 2014, his VA psychiatrist documented a "high" level of PTSD symptoms, including anxiousness. In a November 2014 correspondence, he reported experiencing panic attacks four to five times per week. These levels of anxiety and depression continued to the present according to his VA medical records and did not decrease in severity. Social and Occupational Relationships The Board finds that the Veteran had no occupational relationships as of 2006, at least none that are identified in the record. The Veteran reported that he ceased all occupational contacts when he stopped working as a self-employed flooring installer. (The Board is unsure what exact term the Veteran would like the Board use to describe his prior profession.) The Veteran's social relationships are limited. According to the evidence of record, he has reduced his social circle to those in his immediate family. His closest relationship is with his grandson, whom he and his wife have adopted. He does attend church. His irritability and general symptoms have affected his marriage negatively. There is a lack of evidence beyond these relationships. Rating Analysis During the claim period (from November 22, 2006), the Veteran's PTSD symptoms most closely manifested as occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 38 C.F.R. § 4.130, Diagnostic Code 9411(70 percent rating). Various mental health professionals have offered opinions on the severity of the Veteran's PTSD symptoms. In October 2006, a private psychologist, J.M., opined that the Veteran's PTSD symptoms, to include chronic tension, irritability, intrusive memories, and sleep disturbances, "have substantially interfered with and disturbed his previous level of adjustment." An August 2012 VA examiner opined that the Veteran's PTSD symptoms resulted in occupation and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. Yet, the examiner later remarked that the Veteran's symptoms were "moderate." A June 2014 VA examiner opined that from November 2006 to November 2013, the Veteran's PTSD symptoms ranged from mild to moderate. In June 2014, his private psychologist, J.M., completed a Medical Resource Statement of Ability to do Work-Related Activities. He opined that the Veteran's day-to-day personal function was moderately impaired. The Veteran submitted a second opinion from J.M. dated August 2015 who opined the Veteran's PTSD symptoms "caused him to suffer clinically significant impairment in his occupational adjustment and functioning and continue to cause him personal and social impairment." In September 2015, J.M. completed another report and found that the Veteran's ability to completed work-related tasks had decreased due to increased hypersensitivity to interpersonal contact. A September 2016 VA examiner opined that the Veteran's PTSD symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. A March 2018 VA examiner opined that the Veteran's PTSD symptoms resulted in occupational and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. An April 2020 VA-contracted examiner opined that the Veteran's PTSD symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. What stands out to the Board is that during the claim period, various mental health professionals provided varying opinions, all of which are credible, as to the severity of the Veteran's PTSD symptoms and resulting effects on his occupation and social capabilities. The opinions do not show a consistent progression of worsening or decrease in severity of his symptoms. Rather, to the Board, the opinions indicate each mental health professional had a different interpretation of the severity of the Veteran's disabilities during the claim period. The Board finds no one opinion is more probative than any other opinion. Turning to the Veteran's GAF scores, there are multiple scores to consider from various mental health professionals. In 2008, mental health professionals recorded GAF scores of 45, 45, 49, 49, and 57. In 2011, GAF scores were recorded as 45 and 45. In 2012, he had a GAF score of 50. In September 2013, he had a GAF score of 45. Collectively, the Veteran's GAF scores ranged from 45 to 57 between 2008 and 2013. GAF scores have associated clinical meanings under the DSM-IV, which are as follows: GAF Score Clinical Meaning 100-91 No symptoms and superior functioning in a wide range of activities 90-81 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities 80-71 If symptoms are present, they are temporary and expected reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); slight impairment in social, occupational, or school functioning 70-61 Mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning well, has some meaningful interpersonal relationships 60-51 Moderate symptoms (e.g., panic attacks) or moderate difficulty in social, occupational, or school functioning 50-41 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals) or serious impairment in social, occupational, or school functioning (e.g., no friends, inability to keep a job) 40-31 Impaired reality testing (psychosis) or communication or major impairment in work or school, family relations, judgment, thinking, or mood 30-21 A person experiences delusions or hallucinations or serious impairment in communication or judgment or is unable to function in almost all areas (e.g., no job, home, or friends) 20-11 In danger of hurting self or others (e.g., suicide attempts; frequently violent; manic excitement) or may fail to maintain minimal personal hygiene or significant impairment in communication (e.g., incoherent or mute). 10-1 Patient is in persistent danger of severely hurting self or others or persistent inability to maintain minimal personal hygiene or has attempted a serious suicidal act with a clear expectation of death 0 There is inadequate information to evaluate an individual The Veteran's scores generally indicate PTSD symptoms consistent with moderate or serious symptoms. The Veteran's symptoms do coincide with these scores, to include his anxiety, sleep disturbances, and suicidal ideations. But what is not associated with these scores are the Veteran's hallucinations/delusions, which have existed continuously throughout the claim period. In addition, the Veteran's chronic sleep disturbances are severe, which the Board believes are not adequately encompassed by his GAF scores. Overall, the Board finds the GAF scores are minimally probative of the actual severity of his PTSD symptoms. A significant factor to the Board is how the Veteran's PTSD symptoms affect his social and occupational relationships. The Veteran has repeatedly told mental health professionals that he has reduced his social circle and cut all ties related to his occupational circle. The Veteran's family members, to include his niece, brother, and wife, have provided statements that confirm his social isolation. Under the 70 percent rating criteria, one of the considerations is the Veteran's "inability to establish and maintain effective relationships." The evidence of record demonstrates that the Veteran does not have the required skills to establish and maintain effective relationships. His general mood, which has been marked by constant depression, fatigue, and sadness, generally prevents him from establishing any meaningful relationships. In addition, he avoids crowds and gatherings, preferring to isolate himself if he is around others. The relationships he does have are not necessarily effective, as his family members have described how he does not interact at social functions. His wife has also credibly described the increasing difficulty she has had communicating with the Veteran due to his PTSD symptoms, such that they sleep in separate rooms. The Board concludes the Veteran's PTSD symptoms prevent him from establishing and maintaining effective relationships. When considering the evidence as a whole for the entire claim period, and resolving reasonable doubt in the Veteran's favor, the Board finds that his PTSD symptoms most closely manifested as occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 38 C.F.R. § 4.130, Diagnostic Code 9411(70 percent rating). 100 percent rating criteria The Board concludes that the Veteran's PTSD symptoms did not result in total social and occupational impairment during the claim period. 38 C.F.R. § 4.130, Diagnostic Code 9411(100 percent rating). Within his briefing and lay statements submitted to the Board, the Veteran relies heavily on his private psychologist, J.M.'s, evaluations and opinions in requesting a 100 percent disability rating. The Board finds, however, that J.M.'s opinion weigh against award a 100 percent rating. Notably, in the October 2006 opinion, he said the Veteran's PTSD symptoms "have substantially interfered with and disturbed his previous level of adjustment." He did not use the words "totally" or "completely." Nor did he use such language in his August 2015 opinion, instead stating the Veteran suffered "clinically significant impairment." In no opinion did J.M. indicate the Veteran was totally impaired. The opinions most closely resemble the criteria associated with the 70 percent rating. The Board acknowledges that the Veteran did display severe symptoms involving auditory and visual hallucinations or delusions during the claim period, which are associated with the 100 percent rating criteria. But the presence of this single symptom is not dispositive to the Board. The Veteran did not display gross impairment in thought processes or communication; 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; memory loss for names of close relatives, own occupation, or own name. While he did state he had problems with his short-term memory, the Board does not find the severity of any short-term memory issues rise to the level of total impairment. The Board finds no evidence that any memory issues related to disorientation, loss of memory regarding his own name or those of close family members, nor is there evidence that any memory issues affected his daily activities to the point he was totally impaired and unable to accomplish tasks. Considering the evidence of record as a whole, the Veteran's PTSD systems did not result in total social and occupational impairment. 3. Entitlement to a total disability rating based on individual unemployability prior to August 16, 2018, is granted. TDIU A request for TDIU is not a separate claim for benefits but rather "is merely an alternate way to obtain a total disability rating without being rated 100 percent disabled under the Rating Schedule." Norris v. West, 12 Vet. App. 413, 42021 (1999). According to 38 C.F.R. § 4.16(a), a veteran who does not qualify for a schedular 100 percent disability rating may be entitled to TDIU if the veteran is unable to secure and follow substantially gainful employment by reason of his or her service-connected disabilities and: 1. The veteran has one service-connected disability rated at 60 percent or more; or 2. The veteran has two or more service-connected disabilities, at least one of which is rated at 40 percent or more, and the combined rating of all service-connected disabilities is 70 percent or more. If the veteran meets the foregoing schedular criteria, then the Board will inquire whether the veteran is unable to secure and follow substantially gainful employment by reason of his or her service-connected disability. 38 C.F.R. § 4.16(a). For VA purposes, the term "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91. VA General Counsel precedential opinions are binding on the Board. 38 U.S.C. § 7104(c); 38 C.F.R. § 14.507. "Substantially gainful employment" includes two components: a noneconomic component and economic component. The noneconomic component considers whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). When determining whether a veteran can "secure and follow substantially gainful employment," the Board, as appropriate, should consider: 1. The veteran's history, education, skill, and training; 2. Whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities (i.e., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and 3. Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Id. (citations omitted). The Board is precluded from considering the Veteran's age, previous unemployability status, and impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.17, 4.19; see Pederson v. McDonald, 27 Vet. App. 276, 286. The economic component considers the Veteran's ability to earn more than marginal income as determined by the U.S. Department of Commerce as the poverty threshold for one person. Ray, 38 Vet. App. at 72; 38 C.F.R. § 4.16(a). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16(a); see Ortiz-Valles v. McDonald, 28 Vet. App. 65, 70 (2016). "[A] veteran can establish marginal employment either by demonstrating an income less than the poverty threshold established by the U.S. Census Bureau or by the facts of his [or her] particular case." Id. at 71 (emphasis added). Marginal employment on a facts-found basis includes, but is not limited to, employment in a protected environment, such as a family business or sheltered workshop, even when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). "Protected environment" is not defined by statutes or VA regulations, but the Board finds that it generally means a work environment in which the employer makes special and significant accommodations beyond those reasonably required by law and that are reasonably necessary to accommodate the veteran. In this respect, the Board is mindful of the Americans with Disabilities Act (ADA), especially its mandate that employers provide reasonable accommodations for individuals with disabilities such as "job restructuring, part-time or modified work schedules, . . . [and] acquisition or modification of equipment or devices." 42 U.S.C. § 12111(9)(B). Where a veteran's employer is required by law to provide reasonable accommodations pursuant to the ADA and those accommodations allow the veteran to engage in a substantially gainful occupation, a TDIU award would, in effect, constitute a second paycheck on the back of the taxpayer. In short, the economic component simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person, and that the noneconomic component requires the Board to fully explain why it concluded a veteran was capable of such employment. Ray, 31 Vet. App. at 73. The ultimate issue of whether TDIU should be awarded is not a medical issue; rather, it is a determination for the adjudicator based on all individualized facts and circumstances. Id. at 72, 7576. Effective Date - TDIU Depending upon the status of a veteran's adjudicated disabilities at the time he or she presents evidence of unemployability, the issue of whether a total disability rating will be assigned on this basis will be handled either during the determination of the initial disability rating assigned at the time the underlying disability (or disabilities) are found to be service connected or, if the veteran later asserts that his or her disability (or disabilities) has worsened, as a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 45354 (2009). When a veteran seeks TDIU while VA is adjudicating the underlying disability or while the administrative appeal of the initial evaluation assigned for that disability is pending, it is part and parcel of the underlying disability claim. Id. at 454; see also Mayhue v. Shinseki, 24 Vet. App. 273, 28182 (2011); 38 C.F.R. § 3.156(b). Generally, the effective date for an initial award TDIU is the date of receipt of the claim/request or the date entitlement arose, whichever is later. 38 U.S.C.§ 5110(a); 38 C.F.R. § 3.400(o)(1). As TDIU cannot be awarded absent a service-connected disability, "[t]he effective date of TDIU cannot be earlier than the effective date of the award of service connection for the disability or disabilities upon which the award of TDIU is based." Delrio v. Wilkie, 32 Vet. App. 232, 248 (2019). Where a claim for TDIU is made after an initial award of compensation for a service-connected disability, such that it is analogous to a claim for increased compensation, the general rule under 38 U.S.C. § 5110(a) and 38 C.F.R. § 3.400 is that the effective date of an increase in a veteran's disability compensation shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefor. Dalton v. Nicholson, 21 Vet. App. 23, 3234 (2007) (applying the rules for increased-rating claims to claims for TDIU after initial compensation). 38 U.S.C. § 5110(b)(2) provides an exception to this general rule: "The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." See also 38 C.F.R. § 3.400(o)(2). Thus, a veteran who is awarded TDIU based on an already service-connected condition, which later renders him or her unable to secure or follow substantially gainful employment, is entitled to consideration of an effective date pursuant to section 5110(b)(2). Dalton, 21 Vet. App. at 34. Thus, two effective dates are possible in TDIU cases: (1) If TDIU is warranted at the time of an initial service connection on which TDIU is based, then the date on which the criteria is met or the date TDIU was claimed/requested, whichever is later (date entitlement arose) (38 C.F.R. § 3.400(o)(1)); or (2) If TDIU is warranted based on an already service-connected disability, then, the date it was factually ascertainable that the Veteran was unable to secure or follow a substantially gainful employment within the year preceding the claim/request for TDIU (factually ascertainable); otherwise, the date on which the criteria was met or the date TDIU claimed/requested, whichever is later (38 C.F.R. § 3.400(o)(2); Dalton, 21 Vet. App. at 34). Analysis The VA Regional Office awarded the Veteran TDIU benefits effective August 18, 2016, which coincided with the date he received an increased disability rating of 70 percent for his service-connected PTSD. The Board denied entitlement to an earlier effective date in its January 2021 decision. In the parties' Joint Motion to Remand filed at the Court, they stipulated that the assigned effective date of August 18, 2016, for TDIU benefits, was arbitrary and unsupported by underlying reasons or bases. Schedular Criteria Within this decision, the Board has awarded the Veteran an initial disability rating of 70 percent for his service-connected PTSD. As a result, the Veteran now meets the schedular criteria (a single disability rated at least 60 percent disabling) as of November 22, 2006. Substantially Gainful Employment Non-economic Component The record shows that the Veteran completed high school and three years of college. Following discharge, he was self-employed as a floor installer. In VA Form 21-8940, Applications for Increased Compensation Based on Unemployability, he reported that he last worked full-time in 2006. He has not had other education or training since becoming too disabled to work. In VA medical examinations prior to 2016, the examiners opined that the Veteran's PTSD did not prevent him from obtaining employment. The problem with these opinions is that there was insufficient rationale offered to support the conclusions. Therefore, the Board does not find them probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("It is the fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion."). Considering the severity of the Veteran's PTSD symptoms during the claim period, the Board finds that his symptoms prevented him from performing the physical and mental acts associated with substantial gainful employment. First, the evidence overwhelmingly indicates that the Veteran rarely received more than four hours of sleep on average per night, normally being limited to around two to three hours a night. His lack of sleep resulted in decreased energy, motivation, and ability to concentrate. Each of these skills are necessary to accomplish physical tasks. The Veteran also suffered from chronic daytime fatigue, thus reducing his ability to functional physically and mentally in a workplace. Second, the Veteran's social isolation prevented him from working with others, including the public, colleagues, and supervisors. Finally, his auditory and visual hallucinations interfered with his general mental abilities. These symptoms when viewed in light of all other evidence of record reasonably indicate the Veteran lacked the physical and mental abilities required to function in a workplace setting. The Board is unable to conceive of reasonable accommodations that might be offered under the ADA to assist the Veteran given the severity of his symptoms. Economic Component The evidence of record indicates the Veteran did not have employment as of 2006. The poverty threshold for one person, under the age of 65 in 2006 was $10,488.00. United States Census Bureau, Poverty Thresholds, 2006, available at https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html (last accessed Oct. 16, 2021). The poverty thresholds only increased each year following 2006. As the Veteran remained unemployed each year following 2006, his income never exceeded the yearly poverty thresholds. Importantly, the Bord finds that the Veteran, as a self-employed floor installer, was able to make his own hours, accept or decline any work, and work at his own pace. This is the equivalent to having employment in a protected environment. There is no evidence that the Veteran would have been able to accept substantially gainful employment in light of his PTSD symptoms beyond marginal employment. Conclusion Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran was unable to secure and maintain substantially gainful employment as of November 22, 2006, the date he became service connected for PTSD and, pursuant to this Board decision, received an initial disability rating of 70 percent. Accordingly, TDIU benefits are awarded as of November 22, 2006. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, 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.