Citation Nr: 21066372 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 11-04 073 DATE: October 29, 2021 ORDER Service connection for sleep apnea is granted. An initial 70 percent rating for PTSD with other specified depressive disorder is granted. Entitlement to TDIU is granted. REMANDED Entitlement to service connection for diabetes mellitus type II is remanded. Entitlement to service connection for congestive heart failure is remanded. FINDINGS OF FACT 1. The evidence is in relative equipoise as to whether the Veteran's sleep apnea is causally related to his PTSD. 2. For the entire appeal period, the Veteran's PTSD has been productive of occupational and social impairment that more nearly approximates a disability picture manifested by deficiencies in most areas. 3. The effects of the Veteran's PTSD have rendered him unemployable for the entire appeal period. CONCLUSIONS OF LAW 1. Resolving the benefit of the doubt in favor of the Veteran, the criteria for service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. An initial 70 percent rating for PTSD is granted. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 3. The criteria for entitlement to TDIU have been met for the entire appeal period. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1974 to May 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2010 and January 2017 rating decisions of the Department of Veterans' Affairs (VA) Regional Office (RO). In relevant part, this appeal was previously before the Board in August 2020. At that time, the Board denied the claims for service connection for diabetes and congestive heart failure on the merits. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In April 2021, the parties filed a Joint Motion for Remand (JMR) requesting that the Board decision be vacated and remanded. As it specifically pertains to the issue of diabetes, the parties agreed that that April 2020 VA examination, upon which the August 2020 Board denial was based, was inadequate as it did not appropriately address concept of intermediate step. The parties also found that the issue of service connection for congestive heart failure was inextricably intertwined with the issue of service connection for diabetes. The Court granted the parties' Motion by way of a May 2021 Order. These issues are further addressed in the Remand section below. At the time of the August 2020 Board decision, the Board remanded the issues of entitlement to an increased rating for PTSD, entitlement to service connection for sleep apnea, and entitlement to TDIU for additional evidentiary development. As will be discussed in more detail below, the Board finds that there has been substantial compliance with the remand directives from August 2020 regarding the claim for service connection for headaches. See Stegall v. West, 11 Vet. Appl 268, 271 (1998) (holding when a remand is issued, the Veteran is entitled, as a matter of law, the right to compliance with the remanded order). The Board also notes that the Veteran's counsel has supplemented the record with additional evidence and waived RO consideration of that evidence. Service Connection Service connection may be established for a disability resulting from an injury incurred or disease contracted in the line of duty, or for aggravation of a preexisting injury incurred or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Moreover, in the case of arthritis, service connection is granted if arthritis is manifested in service, or manifested to a compensable degree within one year following separation from service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Generally, service connection will be granted on a direct basis when there is competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between the in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). A "veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 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) (citing Gilbert, 1 Vet. App. at 54). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Service Connection for Sleep Apnea The Veteran contends that his sleep apnea was either caused or aggravated by his service-connected acquired psychiatric disorder. Specifically, the Veteran suggests that his sleep apnea was caused by his obesity as a result of his PTSD. This is a permissible theory of service connection under VA law. Pursuant to VAOPGCPREC 1-2017 (Jan. 6, 2017), obesity per se is not a disability subject to service connection. This notwithstanding, under VAOPGCPREC 1-2017, obesity may be an "intermediate step" between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). There are several opposing medical opinions of record. In July 2017, the Veteran underwent an independent medical evaluation conducted by Dr. T.K.G. At that time, the examiner found that the Veteran's PTSD was a significant causative factor in his developing obesity and that his obesity caused his sleep apnea. In so finding, Dr. T.K.G. cited to various medical literature for the premise that PTSD often results in obesity. Specifically, the cited studies demonstrated that PTSD was associated with greater likelihood of obesity. Dr. T.K.G. further indicated that the Veteran's obesity caused his sleep apnea as obesity was a major risk factor for sleep apnea. The examiner also found that the Veteran's PTSD worsened his sleep apnea. In so finding, the examiner cited medical literature for the premise that PTSD significantly decreased effective treatment in sleep apnea. In a February 2020 VA examination, the examiner found that while it was possible that the stresses related to PTSD had a contributory affect to the Veteran's obesity, there was no evidence to support that the Veteran's PTSD is the most important proximate cause or that it superseded any of the other multiple risk factors the Veteran has for obesity. Thus, the examiner found that it was not at least as likely as not that the Veteran's PTSD caused obesity. The examiner also found that there was no credible medical authority or peer reviewed study that demonstrates PTSD as a proximate cause of sleep apnea. In an October 2020 VA addendum opinion, the examiner found that it was unclear whether there is an increased prevalence of sleep apnea in patients with PTSD. However, the examiner further found that there was no physiologic mechanism by which PTSD would or could cause the physical anatomic features that contribute to upper airway collapse during sleep. The examiner further found that while PTSD and sleep apnea were often comorbid conditions, both of which can cause sleep disturbance, the mechanism behind these sleep disturbances are distinct and unrelated to each other. In a February 2021 private medical opinion, Dr. M.B.S. found that the Veteran's sleep apnea was at least as likely as not caused by his PTSD. In so finding, Dr. M.B.S. cited medical literature to support the conclusion that sleep fragmentation associated with PTSD increased the propensity for upper airway collapse in patients with comorbid sleep apnea. In addition, studies from the American Academy of Sleep Medicine found that veterans with PTSD had a high risk of developing sleep apnea. Dr. M.B.S. reasoned that potential factors identified in the studies include disturbed sleep, prolonged sleep deprivation, sleep fragmentation, and hyperarousal due to physical and psychological stressors. Such PTSD symptoms increased the risk for development of sleep apnea. Overall, Dr. M.B.S. found that based on medical studies and objective principles applied to the Veteran's medical history, the Veteran's sleep apnea was at least as likely as not causally related to his PTSD. In light of the above, the Board finds that the evidence for and against the claim is at least in equipoise as to whether the Veteran's sleep apnea is attributable to his service-connected PTSD. When the evidence for and against a claim is in relative equipoise, by law, the Board resolves all reasonable doubt in the Veteran's favor. The Board emphasizes that this standard of proof is "unique" to the VA adjudicatory process in light of the fact that the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding such benefits. Wise v. Shinseki, 26 Vet. App. 517, 531 (2014). See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 55. Therefore, the benefit of the doubt is resolved in favor of the Veteran and entitlement to service connection for obstructive sleep apnea is granted. Increased Rating for PTSD Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Staged ratings are appropriate for any 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is currently rated 50 percent disabling under DC 9411. All psychiatric disorders are evaluated under a general rating formula for mental disorders. 38 C.F.R. § 4.130. Under the general rating formula, a 50 percent rating is assigned for 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, 9411. A 70 percent evaluation is warranted for 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 situations (including work or a work-like setting); and inability to establish and maintain effective relationships. Finally, a total schedular rating of 100 percent is warranted when the disorder results in 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The symptoms listed in the rating schedule 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. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, all ratings in the general rating formula are associated with objectively observable symptomatology, and "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Further, "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Thus, "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. at 118. As such, the Board will consider both the Veteran's specific symptomatology as well as the occupational and social impairment associated with the rating code to determine whether an increased evaluation is warranted. As a preliminary matter, the Board recognizes that during this period, the Veteran was in receipt of a temporary total rating due to his PTSD from June 18, 2013 to August 31, 2013. Accordingly, the ensuing analysis will focus on the time periods when the Veteran's disability was rated 50 percent. Turning to the facts of the case, the Veteran filed a service connection claim for PTSD in January 2010. In contemporaneous medical and lay records, the Veteran reported his mood frequently fluctuated between depressed, to irritable, to manic. He also experienced sleep disturbances, flashbacks, nightmares, avoidance, decreased motivation, and anger. His mental status was within normal limits; he denied suicidal or homicidal ideation and there was no evidence of psychotic symptoms. His treating psychiatrist found that his symptoms were consistent with mania rather than psychosis. He denied experiencing panic attacks or anxiety and remained oriented on all spheres. In addition to PTSD, the Veteran was diagnosed with bipolar disorder and panic disorder. See VA Treatment Records dated January 2010 to March 2010; Statements in Support of Claim dated April 2010 and June 2010. At the July 2010 VA examination, the examiner diagnosed the Veteran with bipolar disorder rather than PTSD. Upon examination, the Veteran continued to endorse anger and irritability, along with sporadic panic attacks, anxiety, and depression. The examiner noted markedly impaired impulse control. He also had nightmares and significant sleep disturbance, evidenced by sleeping 3 to 4 hours a night and frequent awakening. Socially, he demonstrated isolative behavior due to "trust issues" and denied social support and hobbies. He described having a history of road rage and had difficulty maintaining relationships due to his marked impairment in occupational functioning and social activities. Upon mental status examination, the Veteran was oriented on all spheres. There was no evidence of suicidal or homicidal ideation and the Veteran denied experiencing delusions or hallucinations. Based on the above evidence, the RO granted service connection for an acquired psychiatric disorder and granted a 50 percent rating. The Veteran timely appealed, seeking a higher disability rating. In May 2011, the Veteran reported feeling irritable with little provocation, along with nightmares and extreme sleep disturbance. He denied any substance abuse and there was no evidence of suicidal or homicidal ideations. He remained fully oriented, and his mental status was within normal limits. In December 2011, the Veteran reported a recent physical altercation with his girlfriend. He attributed his difficulty with relationships to his anger. He continued to deny suicidal or homicidal ideations and he remained fully oriented. Treatment notes from 2012 and 2013 reflect the Veteran's continued sleep impairment, irritability, anger, and anxiety. He stated that he used coping skills to alleviate his violent behavior. His mental status remained within normal limits and there was no evidence of suicidal or homicidal ideations nor was there evidence of hallucinations, psychosis, or delusions. In November 2013, after the Veteran's inpatient psychiatric treatment, the Veteran experienced a significant improvement in his PTSD symptoms. While he still had nightmares, and periods of tearfulness and anhedonia, the Veteran stated that he was able to recognize his symptoms and cope with them. In an April 2014 treatment note, the Veteran reported improved mood. He denied experiencing suicidal or homicidal ideations and stated that he had positive relationships with family and peers and a strong support system from his wife and daughters. Socially, he played sports and watched television. He remained fully oriented, and his mood was positive and hopeful. At the January 2015 VA examination, the examiner diagnosed the Veteran with other specified depressive disorder and found that he did not meet the diagnostic criteria for any other disability. The Veteran's symptoms included depressed mood and disturbances of motivation and mood. He maintained a good relationship with his children and made a few friends since moving to a new city. Normally he spent time alone and said that his typical mood was a 6/10, which fluctuated depending on the day. He also endorsed difficulty maintaining sleep, along with nightmares; he also reported worrying throughout the day. He experienced anxiety reaction to certain stimulants, and he experienced significant difficulty trusting others. Socially, he maintained a good relationship with his children and was able to have multiple romantic relationships. He also maintained close friendships with other men living in the same health facility. The Veteran's mental status was within normal limits. He remained oriented on all spheres and he denied suicidal and homicidal ideation. While there was some evidence of attention disturbance, he did not endorse delusions or hallucinations. While remote and immediate memory were within normal limits, recent memory was moderately impaired. Ultimately, the examiner found that the Veteran's depressive disorder manifested in occupational and social impairment with reduced reliability and productivity. In an April 2015 psychological consult, the Veteran reported feelings of hopelessness and helplessness along with low mood and impaired concentration. He described experiencing high anxiety and having panic attacks if he felt trapped and cannot find a safe exit. He denied suicidal or homicidal ideation and was fully oriented. He stated that he stopped using alcohol and drugs in 1997. Shortly thereafter, at the May 2015 VA examination, the Veteran continued to endorse anger, impulsive behavior, and irritability along with depressed mood, anxiety, chronic sleep impairment, mild memory loss, and disturbance of motivation and mood. He maintained a decent relationship with his wife and children but did report some physical and emotional distance at times due to his anger. He described himself as a loner but had one friend in the area. The mental status examination yielded normal results. The Veteran remained oriented on all spheres and there was no evidence of hallucinations or delusions. He denied suicidal or homicidal ideation. However, while remote memory appeared unimpaired, the Veteran described some difficulty with recent memory and concentration. The examiner noted that the onset of the Veteran's concentration difficulty was relatively recent and was attributable to his recent medical problems. In subsequent treatment records, the Veteran remained fully alert and oriented. He denied suicidal and homicidal ideations and while his mood fluctuated, his thought process, insight, and judgment remained within normal limits. There was no evidence of hallucinations, delusions, or psychoses. His mood ranged from calm to mildly anxious to depressed. In May 2016, the Veteran stopped psychotherapy, citing improvement in his PTSD symptoms. In June 2018, the Veteran sought to re-engage in psychotherapy after noticing an increase in nightmares and other PTSD symptoms. He described emotional struggles but denied any suicidal or homicidal ideations. In a July 2018 treatment note, the Veteran reported feeling anxious and "down" due to family conflict. His mental status remained within normal limits. At the July 2018 VA examination, the Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks more than once a week, and chronic sleep impairment, along with mild memory loss, flattened affect, and impaired judgment. The examiner also noted that the Veteran endorsed disturbances in motivation and mood, difficulty establishing and maintaining relationships, and difficulty adapting to stressful circumstances. He also experienced intrusive thoughts, avoidance, irritability/anger, concentration difficulty, and exaggerated startled reaction. Socially, the Veteran did not have any friends that he communicated with on a regular basis. The Veteran lived alone; he stated that he could not live with his family due to interpersonal stress "leading to the police being called." Upon mental status examination, the Veteran was fully oriented on all spheres. The Veteran endorsed vague symptoms of hearing voices, but the examiner found that this symptom was not consistent with symptoms of psychosis. While his mood was depressed and his affect flat, the Veteran denied current suicidal or homicidal ideation. Ultimately, the examiner found that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. In September 2019, the Veteran reported increased irritability and short-temperedness due to medical and marital stressors. He stated he experienced passive suicidal ideations without plan or intent. He felt hopeless and helpless at times. While he felt anxious when frustrated, he did not experience panic attacks. In additional to chronic impairment, he felt more paranoid but attributed that to his cannibis use. While he denied issues with concentration and memory, he stated that he recently lost 20 pounds over two months due to decreased appetite. While he stated that drinking was not an issue, he did drink significantly more when depressed. He smoked cannabis two to three times per week, indicating that it helped him cope. In July 2020, the Veteran reported chronic sleep impairment, negative ruminations, anger, and irritability. He stated that he has nightmares and still drank alcohol when depressed. The treating psychologist noted that the Veteran was not compliant with his medication. His mental status was within normal limits and there was no evidence of hallucinations or delusions. At the September 2020 VA examination, the Veteran reported that he maintained regular contact with his children. He denied having any current hobbies or interests and did not have any significant social interaction other than with his immediate family. Upon mental status examination, the Veteran was fully oriented. He denied any delusions or hallucinations and there was no evidence of suicidal or homicidal ideation. His short- and long-term memory appeared to be without gross deficits. In August 2021, the Veteran underwent a private psychological evaluation to assess the severity of his PTSD; the results of that evaluation are documented in a contemporaneous Disabilities Benefits Questionnaire (DBQ). At that time, the Veteran described himself as socially isolated and withdrawn. He lived alone in an RV and was separated from his wife. He reported that in the past, he self-medicated with alcohol and drugs. In addition to depressed mood and anxiety, he also endorsed panic attacks more than once a week along with near-continuous panic or depression, which affected his ability to function independently. He also had chronic sleep impairment, mild memory loss, impaired abstract thinking, and flattened affect. He had difficulty establishing and maintaining effective relationships along with difficulty adapting to stressful circumstances. The examiner noted neglect of personal appearance and hygiene along with suicidal ideation and persistent delusions or hallucinations. He stated that he heard voices and noises when nothing was present. His symptoms resulted in intermittent inability to perform activities of daily living. His children cooked for him and did his house cleaning. Although he managed his finances, he stated he showered and brushed his teeth approximately once a month. Ultimately, the psychologist found that the Veteran's PTSD resulted in total occupational and social impairment. Based on the above, the Board finds that a 70 percent initial rating is warranted. A review of the Veteran's medical records, reports, and lay statements demonstrate that the frequency, severity, and duration of the Veteran's symptoms more nearly approximate that which is contemplated by a 70 percent rating, as his symptoms caused deficiencies in most areas of his life. Since the inception of the appeal period, the Veteran consistently reported isolative behavior, irritability, anger, continuous depression, anxiety, and some memory impairment. Early in the appeal period, the Veteran described being arrested for domestic violence and most recently, the Veteran has started to drink and use cannabis to cope with his PTSD symptoms. For a significant portion of the appeal period, the Veteran lived separately from his wife and children due to his anger and irritability. Although the VA examiners found that the Veteran's acquired psychiatric disorders resulted in impairment with reduced reliability and productivity, the Board finds that the frequency, severity, and duration of the Veteran's symptoms caused deficiencies in most areas. In short, the Board finds that based on the consistency demonstrated by the Veteran's disability picture, a 70 percent rating is warranted for the entire appeal period. The Veteran's symptoms are more characteristic of a disability picture that is contemplated by a 70 percent rating and no more. The Veteran on this record has not demonstrated grossly inappropriate behavior or a persistent danger of hurting himself or others. While the Veteran reported hearing noises in his recent evaluation, the frequency, severity, and duration of these hallucinations are not sufficient to support a 100 percent rating. Although the evidence demonstrates issues with anger and impulse control, such actions do not amount to total occupational and social impairment. The Board acknowledges the August 2021 evaluation which documented the Veteran's neglect of personal hygiene and the fact that his daughters cooked and cleaned for him. However, he has not shown that he was ever disoriented to time or place and had no memory loss so severe as to not recall the names of relatives or his own names. Thus, the Veteran has not demonstrated frequency, severity, and duration of symptoms that have caused total occupational and social impairment in most of the referenced areas for the 100 percent disability rating. See Vazquez-Claudio, 713 F.3d at 116-17. The Board is aware that some evidence of record calls into question the Veteran's ability to secure and follow a substantially gainful occupation. The Board is cognizant of the difference in criteria for a 100 percent rating that is set forth by the rating schedule under DC 9411, see supra, and the requirements for entitlement to a TDIU (addressed below). Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation; a 100 percent PTSD rating involves a showing of total occupational and social impairment based on enumerated symptoms. 38 C.F.R. § 4.16, cf. § 4.130, DC 9411. Thus, marginal, sheltered, or failed employment does not necessarily equate to total occupational and social impairment. In this regard, the evidence addressing the Veteran's unemployability is not probative evidence showing that the Veteran's symptoms more nearly approximate total occupational and social impairment as unemployability does not equate total impairment. In conclusion, the Board finds that the frequency, duration, and severity of the Veteran's PTSD more nearly approximates that which is contemplated by the 70 percent rating and no higher. The appeal is granted to that extent only. Total Disability based on Individual Unemployability For VA purposes, total disability exists when there is any impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, if 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). This regulation provides that consideration of such a rating is warranted if a veteran has one service-connected disability rated 60 percent or more or, if there are two or more such disabilities, there must be at least one that is rated 40 percent or more, with the remaining disabilities combining to 70 percent or more. Id. In this case, the Veteran is service connected for PTSD, now rated 70 percent disabling, and tinnitus, rated 10 percent disabling. Thus, he meets the schedular requirements for a TDIU. The record reflects that the Veteran last worked as a driver in 1991. His employment history also includes work as a deliveryman, a mailroom clerk, and a landscaper. See VA Form 21-8940 dated October 2012. The Veteran did not complete college and does not have any vocational training or certifications. Throughout the appeal period, the Veteran has consistently reported that he stopped working due to his PTSD symptoms. Entitlement to a total rating must be based solely on the impact of a Veteran's service-connected disabilities on his ability to keep and maintain substantially gainful work. See 38 C.F.R. §§ 3.340, 3.341, 4.16. The question in a claim of entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities is whether a Veteran is capable of performing the physical and mental acts required by employment and not whether a Veteran is, in fact, employed. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In Moore v. Derwinski, 1 Vet. App. 356, 359 (1991), the U.S. Court of Veterans Appeals (now the U.S. Court of Appeals for Veterans Claims) (Court) discussed the meaning of "substantially gainful employment." In this context, it noted the following standard announced by the United States Federal Court of Appeals in Timmerman v. Weinberger, 510 F.2d 439, 442 (8th Cir. 1975): It is clear that the claimant need not be a total 'basket case' before the courts find that there is an inability to engage in substantial gainful activity. The question must be looked at in a practical manner, and mere theoretical ability to engage in substantial gainful employment is not a sufficient basis to deny benefits. The test is whether a particular job is realistically within the physical and mental capabilities of the claimant. In this case, in September 1993, the Social Security Administration granted the Veteran employment disability benefits based on his back injury and psychiatric disability. Specifically, SSA found that the Veteran's mental impairments imposed a moderate restriction of activities of daily living and slight difficulties maintaining social functioning. He also demonstrated deficiencies of concentration, persistence, or pace. Ultimately, the SSA found that the Veteran's occupational impairment due to his psychiatric disorder was severe. The Board notes that while findings from SSA are not dispositive or altogether binding on VA, such findings do constitute probative evidence with respect to a TDIU claim, as such findings provide context related to the Veteran's employability. In January 2010, the Veteran reported that he was unable to keep a job for more than 6 months due to his psychiatric symptoms. At that time, he endorsed frequent periods of mania, followed by severe depression. His treating psychologist noted that he was both restless and agitated and at times demonstrated diminished concentration. He also had panic attacks twice per week, which were manifested by shortness of breath, sweating, shaking, chills, choking, and dizziness. His symptoms of anger and irritability caused numerous fights, assaults on his significant others, and road rage. In a June 2010 treatment note, the Veteran stated that he quit working as a truck driver in 1991 due to a back injury. He also stated that he had difficulty "tolerating" people in positions of authority. At the July 2010 VA examination, the Veteran reported having approximately 25 jobs throughout his lifetime, including forklift operator, truck driver, and stocking clerk. He stated that he was unable to maintain employment for more than 6 months due to his mental health problems. He explained having a history of conflict, abrupt quitting, and angry outbursts particularly with authority figures. In March 2012, the Veteran underwent an independent psychiatric examination. At that time, the Veteran reported that he quit his jobs secondary to irritability and fighting. At the time of the examination, the Veteran described being isolative and verbally irritable with people. At the May 2015 VA examination, the examiner found that the Veteran's PTSD symptoms would be exacerbated in a high-pressure work environment. Further, the examiner found that it was likely that the Veteran would experience interpersonal conflict in a work environment. In addition, his difficulty with sustained concentration would impact his productivity at work. In July 2021, the Veteran underwent an independent evaluation by a vocational expert. At that time, Dr. H.J.H. found that based on a 40-hour work week, the Veteran would miss at least 3 days per month due to his service-connected PTSD. She also found that the Veteran would have to leave work early at least 3 days per month and would have significant difficulty staying focused and completely simple repetitive tasks. In addition, Dr. H.J.H. opined that the Veteran's chronic sleep impairment would result in fatigue, which would present safety issues in the workplace. In addition to his anger and issues with authority, Dr. H.J.H. also found that the Veteran's poor interpersonal skills, paranoia, and anxiety would prevent appropriate work interaction and even pose a safety hazard on the job. The Board is of the opinion that the Veteran's PTSD has rendered him unemployable. As noted in Moore, the Board must address the TDIU question as a practical manner. Notably, the Veteran's employment history consists of a wide variety of jobs, including truck driver, forklift operator, stocking clerk, and landscaper. Although the Veteran has experience in several different fields of employment, the Board finds that the nature of his PTSD would, as a practical manner, prevent him from maintaining employment in any field. The record demonstrates that the Veteran is unable to maintain employment for a significant amount of time. Based on the opinions of the medical and vocational professionals, the Veteran's symptoms, to include anger, irritability, chronic sleep impairment, and diminished concentration, would not only impair his productivity at work, but would also pose significant safety hazards in the workplace. The frequency, severity, and duration of his PTSD symptomatology makes employment unrealistic. Considering the entire record as outlined above, and in light of the combined effects of the service-connected PTSD, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the evidence supports an award of TDIU. The claim is granted. REASONS FOR REMAND While further delay is regrettable, the Board finds that remand is required to comply with the instructions of the Joint Motion for Remand (JMR). The Veteran is seeking service connection for diabetes and congestive heart failure, which he contends are both secondary to his obesity that he alleges that he developed because of his PTSD. In the March 2021 JMR, the parties agreed that the April 2020 VA examination, upon which the Board's August 2020 denial was based, was internally inconsistent. Consequently, another remand is required to obtain an adequate medical opinion. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriately qualified clinician to provide opinion as to whether it is at least as likely as not that the Veteran's PTSD resulted in any weight gain and, if so, identify the approximate gain of weight attributable to the PTSD. The examiner is instructed to consider that, if any extent of weight gain cannot be attributed to service-connected PTSD due to service-connected PTSD versus nonservice-connected causes, the examiner should attribute the weight gain to service-connected PTSD. If such a determination is medically speculative in nature, the examiner should explain why such a non-speculative opinion is beyond the limits of medical knowledge. 2. After the opinion regarding obesity is obtain, forward the Veteran's claims file to a qualified examiner for an opinion addressing the etiology of the Veteran's diabetes. The examiner should answer the following questions: (a.) The examiner should refer to the examination report obtained by the AOJ regarding weight gain. If additional weight gain is deemed attributable to service-connected PTSD, is it at least as likely as not (i.e., probability of 50 percent or greater) that the extent of weight gain caused the Veteran's diabetes; OR (b.) Is it at least as likely as not that the extent of weight gain caused any additional functional impairment of the diagnosed diabetes (e.g., an increased severity of symptoms even if temporary); OR (c.) Is it at least as likely as not diabetes would have occurred but for obesity caused or aggravated by service-connected PTSD? The need for further in-person examination is left to the discretion of the examiner. A complete medical rationale for all opinion expressed must be provided. 3. Forward the Veteran's claims file to a qualified examiner for an opinion addressing the etiology of the Veteran's congestive heart failure. The examiner should answer the following questions: (a.) If the Veteran's diabetes is determined to be service-connected, the examiner should opine as to whether it is at least as likely as not that the Veteran's diabetes caused his congestive heart failure? (b.) Is it at least as likely as not (50 percent probability or greater) that diabetes, results in any additional functional impairment associated with congestive heart failure (e.g., a medically discernable increase in frequency, duration, and/or severity, even if temporary, above the degree associated with that expected from his baseline congestive heart failure disorder alone)? The examiner is requested to discuss whether the underlying diabetes (if service-connected) is medically capable of causing or aggravating congestive heart failure, and if so, whether the Veteran's congestive heart failure has been caused or aggravated by diabetes based on the particular facts of this case. (c.) The examiner should refer to the examination report obtained by the AOJ regarding weight gain. If additional weight gain is deemed attributable to service-connected PTSD, is it at least as likely as not (i.e., probability of 50 percent or greater) that the extent of weight gain caused the Veteran's congestive heart failure; OR (d.) Is it at least as likely as not that the extent of weight gain caused any additional functional impairment of the diagnosed congestive heart failure (e.g., an increased severity of symptoms even if temporary); OR (e.) Is it at least as likely as not congestive heart failure would have occurred but for obesity caused or aggravated by service-connected PTSD? The need for further in-person examination is left to the discretion of the examiner. A complete medical rationale for all opinion expressed must be provided. 4. Thereafter, readjudicate the claims. If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and an appropriate period of time to respond. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Orie, 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.