Citation Nr: 21068244 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 16-23 309 DATE: November 9, 2021 ORDER Entitlement to total disability rating based on individual unemployability due to service-connected disabilities (TDIU) from April 23, 2012 to January 27, 2014 is denied. Entitlement to TDIU from January 27, 2014 to June 7, 2018 is granted. FINDINGS OF FACT 1. For the period from April 23, 2012 to January 27, 2014, the Veteran was singularly service connected for other specified traumastressor-related disorder with specific phobia (needles) with a 70 percent rating. 2. For the period from January 27, 2014 to June 7, 2018, the Veteran has a 70 percent rating for other specified traumastressor-related disorder with specific phobia (needles), and a 30 percent rating for migraine headaches, with a combined schedular disability rating of 80 percent. 3. The Veteran has a high school education, and a work history of 13 years in food service, five years in housekeeping/general cleaning, and 13 years in part-time sales; the Veteran last worked full time in 2005, and last worked in October 2012. 4. The service-connected psychiatric disorder did not prevent the Veteran from obtaining and maintaining substantially gainful employment prior to January 27, 2014. 5. For the period from January 27, 2014 to June 7, 2018, the service-connected psychiatric disorder and migraine headaches prevented the Veteran from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to TDIU from April 23, 2012 to January 27, 2014 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.16(b). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for TDIU from January 27, 2014 to June 7, 2018 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Army from September to November 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The March 2016 rating decision granted service connection for "other specified trauma--stressor-related disorder with specific phobia" with an initial 50 percent rating, effective April 23, 2012. A June 2018 rating decision provided a 70 percent rating, effective April 23, 2012. A March 2019 rating decision provided a 100 percent rating, effective June 7, 2018. As such, the claim for TDIU is limited to the period prior to June 7, 2018, as the exceptions to the rule that a 100 percent rating moots a TDIU are not raised in this case. An October 2020 rating decision granted service connection for migraines, with an initial 30 percent rating effective January 27, 2014. Another October 2020 rating decision provided a 50 percent rating for the headaches from August 20, 2020. The Veteran appeared and testified at personal hearings in December 2018 and January 2019 before two of the undersigned Veterans Law Judges (VLJs). Transcripts of both hearings are contained in the record. The December 2018 hearing addressed service connection for a low back disability, migraines, allergies, and TDIU. An April 2020 Board decision reopened service connection for a low back disability, and denied entitlement to service connection for a low back disability and migraines. A decision regarding service connection for allergies has not yet been issued, and will be provided in a separate Board decision. The January 2019 hearing addressed the Veteran's claim of entitlement to an increased rating for the service-connected psychiatric disorder and entitlement to TDIU. A July 2019 Board decision denied a rating in excess of 70 percent for the psychiatric disorder. As both Board hearings addressed the issue of TDIU, a November 2020 letter informed the Veteran that a decision regarding her TDIU claim would be decided by a three-judge panel. The November 2020 letter offered the Veteran the option of a third hearing, to be held by a third Veterans Law Judge, and allowed 30 days from receipt of the letter to respond or the Board would presume that the Veteran did not wish to participate in a third hearing. No response was received within 30 days, so the right to a third Board hearing is waived. 1. Entitlement to TDIU from April 23, 2012 to January 27, 2014 is denied. 2. Entitlement to TDIU from January 27, 2014 to June 7, 2018 is granted. The Veteran contends that for the period on appeal, from April 23, 2012 to June 7, 2018, she has been rendered unable to maintain substantially gainful employment due to service-connected disabilities. A 100 percent schedular rating has been in effect from June 7, 2018. The Veteran's psychiatric claim was on appeal from an April 23, 2012 claim date. A July 2012 rating decision found that new and material evidence was not submitted to reopen a claim of entitlement to service connection for a psychiatric condition. In September 2012, the Veteran submitted new and material evidence and in July 2013 she submitted a stressor statement. As such, the claim remained open. She filed an informal claim for service connection for migraines on January 27, 2014, and in February 2014 filed another claim for both the psychiatric disorder and for migraines. The Veteran continued the appeal, resulting in a March 2016 rating decision grant of service connection for other specified trauma disorder. The Veteran then appealed the initial rating assigned in the March 2016 decision. As such, the psychiatric rating issue has been on appeal since the April 23, 2012 claim date, and the TDIU attached to this open rating issue. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a TDIU is part of an increased or initial rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. As such, the Veteran's claim for TDIU is considered on appeal from April 23, 2012. Total disability ratings for compensation may be assigned, where the schedular rating is less than 100 percent, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of one or more service-connected disabilities without regard to advancing age or nonservice-connected disability. See 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a); Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993) (holding that the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability); see also 38 C.F.R. § 4.19 (unemployability associated with advancing age or intercurrent disability may not be used as a basis for a total disability rating). Marginal employment is not considered substantially gainful employment. 38 C.F.R. §§ 3.340, 4.16(a). Substantially gainful employment means, essentially, that the work provides income above the poverty level established by the United States Department of Commerce, without benefit of protected family employment or a sheltered workshop. 38 C.F.R. § 4.16 (a). Factors to be considered in determining entitlement to TDIU include, but are not limited to, employment history, educational achievement, and vocational attainment. Age is not a factor. 38 C.F.R. § 4.16 (b). A total disability rating for compensation may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. See 38 C.F.R. § 4.16 (a). From April 23, 2012 to January 27, 2014 For the period from April 23, 2012 to January 27, 2014, the only service-connected disability was specified trauma psychiatric disorder, rated at 70 percent. This disability meets the rating combined rating percentage requirement for TDIU eligibility under 38 C.F.R. § 4.16(a) for the period on appeal. After reviewing all the medical and lay evidence, the Board finds that the service-connected mental health disability alone did not render the Veteran unable to obtain or maintain substantially gainful employment from April 23, 2012 to January 27, 2014. The Veteran initially submitted a claim of entitlement to TDIU in March 2011. At that time, she did not have a service-connected disability. On the form, she reported she was unable to work due to back pain, depression, and foot/toe injury. Veteran reported that she had a high school education. The employment history included full-time employment for a school system from September 2000 to January 2005 as a general cleaner, part time as a cashier for a movie theater from November 1998 to the "present" (March 2011), that she had applied to work for the School district of Philadelphia as a food service worker and a general cleaner in March 2010, worked as a cashier at Kmart in February 2010, and worked for the school district in September 1987 in food service, that she then passed a test and worked for ten years as a school cook until she "retired" in March 2000, and that five months later she went back to work for the school district as a "general cleaner" until January 3, 2005. An accompanying March 2011 statement included that the Veteran had hurt her back in the 1990s. She stated that she retired in March 2000 and went back to work in August 2000, and then worked until she "was hurt" in 2005. She stated that at one point in her life, she was working three jobs, felt "worthwhile" when she was working, and then lost her foster mother and father, and her birth mother all within a year (2005-2006). She did not mention headaches in this statement or in the claim for TDIU. An April 20, 2011 VA initial psychiatric note included that "for the past 12 years [the Veteran had] worked as a ticket booth cashier for a movie theater, part time. She enjoys the contact with the customers, despite being stuck in the booth all the time." The Veteran participated in ongoing VA psychotherapy every 2 to 3 weeks for several years. There is a significant amount of mental health treatment records contained in the electronic file. The Board refers to the findings in the July 2019 increased psychiatric rating decision. A May 24, 2012 VA mental health record included that the Veteran was recently hired for a new part-time job and she was very excited about this. A June 28, 2012 VA mental health record included that the Veteran reported that her psychiatric symptoms had improved following a period of starting a new job and then resigning from the job because of difficulties working due to physical problems. She stated that it was "very upsetting to her to recognize that she [was] unable physically to do everything she used to be able to do." She also reported she had stopped singing in choir because it required too much standing. She was considering taking medication for her depression. She stated she had "been more active again over the last month and this has been helpful." During this period, the Veteran additionally applied for Social Security Disability Income (SSDI). On a June 1, 2012 form for SSDI, the Veteran reported a work history as a cashier at a theater from 1999 to the present, for the school in food service from 1987 to March 2000, and for the school as a cleaner from September 2000 to January 2005, and worked for Macy's department store from May 26, 2012 to the "present." Regarding the cashier job, the Veteran reported she sold movie tickets, greeted customers, removed trash, cleaned the box office, and would lock up at the end of the night. Regarding the job at Macy's, the Veteran reported she worked 4 hours per day, 3 days per week, and that the job entailed helping customers find items, and using a cash register. She felt that there was "so much to remember" at that job. She noted that she walked around to make sure everything was in order, and that it required "standing too long." She stated she "told them about [her] back" and hoped she would not have to resign. In the remarks section, the Veteran noted she had been working on and off since she was 16 years old and that she "felt good when [she] was working." She stated she could not work "because of [her] injury." She stated that being hired by Macy's recently made her feel good about herself. A June 2012 SSDI form completed by the Veteran's husband included that the Veteran's hand pain and back pain were limiting to her, and that she wanted to be able to work. He also noted that the stress and depression made it so he "did not know who he was waking up to." Socially, the Veteran had a female friend that she spoke on the phone with "every day for hours." She also went to church, to a nursing home the first Sunday of each month, and she worked 2 to 3 times per week. He stated that she would be angry for no reason, and sometimes would cry (the frequency of these symptoms was not stated). Regarding her ability to get along with authority figures, the husband noted as "good as long as they don't cross her. She [is] a good person, people try to get over on her." A July 23, 2012 Bureau of Disability Determination included an interview and evaluation of the Veteran's disability claim. When asked why she applied for benefits, she reported "emotional and physical problems." She stated she was injured on the job in January 2005 when she injured her right foot while sweeping steps. She complained of arthritis in her back, right foot, and both hands. She also reported feeling very depressed since childhood; noting she was placed in foster homes from the age of 2 months. She reported feeling abandoned and having a lot of anger, but that it had "abated as she got older." "When asked why she was not able to work, she responded that she finds it difficult to sit and stand." She continued "to work in a movie theater one day a week" for the past 13 years. "When asked what conditions limit her ability to work, she responded because of her depression and at times, a reluctance to get up. She claims to not leave the house and was made to resign from her job resulting in her feeling 'useless'... she complained that it is getting difficult for her to sit or stand for any extended period of time because of foot and back pain. She also reported feeling depressed for all of her life." She was able to complete self-care and shop independently. She reported "having some friends." During the evaluation she "presented as mildly depressed." There was no evidence of lethargy. A July 30, 2012 SSA evaluation included the Veteran's complaint of multiple medical complaints and reported physical limitations as well as a lack of motivation due to dysthymia. However, a July VA treatment record was cited regarding her improved symptoms. "Psychiatric symptoms and limitations appear to be minimal...symptoms are mild, and she is reporting to be more active...claimant's alleged limitations appear more physical per her recent job experience and as such are only partly credible." A September 20, 2012 mental health note included that the Veteran was "disappointed over expectations that she'd be verified as disabled for work when in fact there is not enough basis for that." She reported feeling more symptoms of depression in the past month. She did not want to do anything and had been spending more time in her room. She identified her daughter moving back in with her and not being able to work anymore as her current stressors. An October 3, 2012 SSDI case analysis included review of VA treatment records from July 2012. She was noted to be capable of working a 40-hour work week without significant interference from psychological symptoms. A November 5, 2012 occupational therapy record included the Veteran's report of her hand "pain makes it difficult to count money." A March 21, 2013 VA mental health record included the Veteran's report that she had difficulty not working because she had always worked hard to stave off feeling sad. She reported she rejoined the choir at church. The mental health provider believed it was time for her to discontinue therapy as she was "coping well." During a psychiatrist visit on the same day, it was noted that the Veteran's mood was "sometimes up and down," but that she did not have "serious symptoms of depression." This record noted that the Veteran lived with her husband of 31 years, her daughter, and granddaughter. She had been working at a movie theater part-time until December 2012 when she was "laid off." On August 2, 2013, the Veteran reported to her VA therapist that she was more depressed following a recent incident where the Veteran applied for and was rejected for a job from the school district. "Although she is unable to work for the school district since she signed a settlement with them stating that she can no longer be employed by them several years ago, [the Veteran] reported that she still felt rejected." She stated that "after she received the recent rejection, she spoke to her husband about it and he was able to help her." They discussed "increasing positive activity since she [was] unable to work...the possibility of volunteering at a soup kitchen." The Veteran "was visibly brighter at the end of session." An August 21, 2013 VA rheumatology note included the Veteran's report of bilateral hand and wrist pain, bilateral foot pain, and left hip pain. "She had to stop working as a housekeeper with the Philadelphia School district due to limitations caused by her hand pain." An October 2013 SSDI determination found that the Veteran became disabled on May 25, 2012. She had initially alleged disability from January 2005. The SSDI judge considered her impairments of depression, bereavement, osteopenia, and degenerative disc disease (lumbar) to be "severe" because "they caused more than minimal limitations in her ability to perform basic work activities." The SSDI Judge found her headaches to be "non-severe in that the medical evidence does not establish any abnormality that would have more than a minimal effect on the [Veteran's] ability to work." The report included that the Veteran's headaches were "occasionally noted" in the treatment records, but did not "seem to create any significant limitations." The Board notes that these are findings based on SSA regulations. The agency determined that the Veteran did not have a severe mental impairment. During a hearing for SSA benefits, the Veteran reported having a fall in October 2012 and that she stopped working in December 2012. The Judge cited an October 2012 record wherein the Veteran reported she was happy that she was walking more now. SSA disability benefits were granted for affective/mood disorders, and osteoporosis, with a disability onset date of May 25, 2012. This date was provided as it was the date of the Veteran's age change (where SSA disability benefits consider the age of the claimant). As noted in the 2019 Board decision regarding the appeal for a higher rating for the psychiatric disability, the RO provided a 70 percent rating for this period on appeal, which the Board will not disturb. However, many of the Veteran's symptoms ranged between the criteria for 30 percent and 50 percent ratings. The symptoms included suspiciousness, anxiety when in crowds or confronted by women, depressed mood, irritability, anger without periods of violence, occasional isolation (by self-report), feelings of worthlessness, low self-esteem, and mild memory loss. The Veteran has argued that she is unable to work due to the mental health condition because she has trouble getting along with others, has a "violent" temper (is afraid she would hurt others or herself), and also that her depression makes her unmotivated and anti-social/reclusive. The Board finds that these symptoms are not supported by the probative medical and lay (the Veteran's statements to treatment care providers) evidence of record. Her VA mental health records (as outlined in greater detail in the July 2019 Board decision) from 2011 to 2018 (and beyond) consistently show that she is able to control her anger. She has reported using humor, walking away, being appropriately assertive, and avoidance of known stressors to appropriately manage her anger and instances where she felt she may be angry. The Veteran initially sought mental health treatment in 2011, but reported to VA and SSA providers that she had been depressed for most of her life. She has also stated that her discharge from service for being pregnant, and the treatment she received (feeling bullied and a racial slur used against her) resulted in a "deep depression" after discharge. She has stated that her depression and anger continued from service to the present, and even that her anger decreased as she got older. As such, the Veteran's employment (including full-time employment from 1987 to 2005) occurred while she was dealing with similar mental health symptoms, and prior to receiving any therapy or prescribed medications to help address her mental health symptoms. The employment from 1987 to 2000 as a cook/food service involved interaction with others. Employment from 1999 to 2012 involved costumer service. She was not reprimanded or fired from any job. She "retired" from the food service full-time employment, and (although she has provided conflicting details) appears to have been laid off from her cashier job when the movie theater closed. From 2000 to 2005, the Veteran was employed in housekeeping/general cleaning which allowed her to normally work independently. She has reported one instance in those 5 years of being asked to "group clean." She testified that she reacted poorly to this request (took her supervisor's "head off"), but apologized. There is no indication she was reprimanded, so the severity of her reaction to her supervisor did not interfere with her employment even if she recognized that it was not an appropriate reaction. Although the Veteran's employment as a cashier was part-time, and would be considered "marginal," it does support her ability to interact with the public for long periods of time without incident, for 12 years. As such, during the work history from 1987 to 2012, the Veteran's psychiatric condition did not interfere with the ability to work. The Veteran has stated she had to take "a year off" of working due to "stress." It is not clear from the record when this year occurred. She does have a gap of 5 months of full-time employment in 2000. The record does not contain any information regarding why the Veteran retired from food service with the school district in 2000, only to apply for a cleaning position with the school district 5 months later. However, she did maintain part-time employment during this gap, again in a customer-service position. The record does not support that the Veteran had a change in mental health symptoms from the periods of employment to the period of unemployment or retirement that would indicate that she could not continue to perform the occupational tasks required of her prior employment (cleaning, cook, food service) or as a full-time cashier based on her mental health disability alone. As shown above, the Veteran reported to SSDI and VA providers that she was limited in her ability to work due to physical disabilities. She reported she was unable to stand or sit for long periods due to her back and foot injuries, and she was unable to work with her cash register or in her cleaning capacity due to hand pain. She had previously maintained employment with her psychiatric symptoms from service discharge onward. Indeed, she reported that her anger had decreased with age. She was able to maintain social relationships with her family, friends, and within her church. She was motivated to attempt additional employment, although she reported she was unable to continue working due to physical limitations. In addition, during this period, the Veteran was participating in choir, very active in her church, and volunteering at a nursing home monthly. As such, the Board finds that the Veteran's psychiatric symptoms alone, for the period prior to January 27, 2014, did not result in the inability to obtain and maintain substantially gainful employment. From January 27, 2014 to June 7, 2018 During the period from January 27, 2014 to June 7, 2018, the Veteran had a combined schedular disability rating of 80 percent due to a 70 percent rating for her psychiatric disorder and a 30 percent rating for migraine headaches. The service-connected disabilities meet the combined disability rating requirement for TDIU eligibility under 38 C.F.R. § 4.16(a) for the period on appeal. After a review of all the evidence, the Board finds that the evidence is at least in equipoise on the question of whether the service-connected psychiatric disability and migraine headache disability combined to render the Veteran unable to maintain substantially gainful employment from January 27, 2014 to June 7, 2018. The evidence includes a September 2014 statement from a friend that the Veteran "had to take a leave of absence to seek help dealing with her depression and migraine headaches" in the 1990s while working for the school district. A September 9, 2014 record included the Veteran's report of increased headache frequency, with a headache 20 out of 30 days the month prior, with blurred vision, nausea, and light sensitivity. She reported no relief from Sumatriptan. A September 11, 2014 treatment record noted that the Veteran had been seen two days before with a bad headache, that had been ongoing for weeks. She stated she was "feeling great" and her headaches were gone after one dose of Sumatriptan. She stated she was feeling much better and "headache-free." An October 2014 record showed that the Veteran's brain MRI was within normal limits. The Veteran stated that her headaches were "well controlled when she takes the Triptan, but still getting quite a few" per week. She was having more headaches due to "stress." She did not want to take preventative headache medicine. The record contains an October 2014 private initial psychological evaluation by Dr. H.J.C. that is addressed thoroughly in the 2019 Board decision regarding the higher rating for the service-connected trauma disorder. The 2019 Board decision described in detail how the symptom severity and descriptive information provided in the 2014 evaluation conflicted with the information throughout the ongoing mental health treatment records. As such, the Board previously found the October 2014 evaluation to be less probative than her ongoing VA mental health treatment records. A December 2, 2014 VA MHC record noted the Veteran was in a "very nice mood today, smiling and chatting about how she hosted family at her house for Thanksgiving." On February 24, 2015, the Veteran reported that her mood was "good today, bright smiling affect as is typical" despite some medical symptoms. She happily described some new births in her family and was looking forward to attending a baby shower. In May 2015, the Veteran reported that her mood was down associated with three recent deaths in the family, including the loss of her youngest brother. She had also been feeling more depressed prior to these losses because of the denial of her disability claims. Her antidepressant medications were increased. In October 2015, the Veteran testified at a RO hearing that she had migraine headaches "about every day" and state she had a "slight one" during the hearing. Her headaches sometimes lasted for a week or more, and that her migraine medication made her drowsy. She treated her headaches by lying in the dark, staying still, and "turning everything off." She stated a "trigger" for her headaches was "getting upset." Her husband testified that "sometimes" the Veteran would have a headache "every day," and sometimes she would have them "periodically" or once per week. He stated that "sometimes she's groggy with the medicine," and he had to do the shopping and chores. A November 20, 2015 record included the Veteran's report of "migraines" when she "gets upset." She stated she was having headaches twice per week and trying to use Sumatriptan sparingly. She had used it 3 to 4 times, and reported it helped. In February 2016, the Veteran participated in a VA PTSD examination. Regarding her work history, the Veteran stated she was never fired from jobs, but instead resigned or quit. She had never been reprimanded at work. A prior manager, for the school, informed her that her attitude changed when other women arrived at work. She felt she worked better alone. She stated she "went out on disability in 2012 due to back pain and not being able to lift things, and her migraines. She did miss time from work when she took a leave of absence for one year due to stress." She reported an incident of a "flashback of being at Ft. Jackson while she was at work" at Macy's in 2011. She stated she "immediately" quit that job. The Board notes that she reported quitting her Macy's job due to standing too much to SSA evaluators. The examiner noted that the Veteran's psychiatric diagnosis resulted in occupational and social impairment with reduced reliability and productivity (50 percent rating criteria). On March 21, 2016, the Veteran called VA seeking a change in medication due to a 4 out of 10 severity headache. She was asked to test her blood pressure, but she did not want to. She also had some pains in her right side, and she was advised to go to the Emergency Department, which she refused. On March 22, 2016, the Veteran participated in a VA headache examination. She reported nausea, sensitivity to light, pulsating or throbbing head pain that worsened with physical activity, sensitivity to sound, and changes in vision (not described). Her typical head pain lasted 1 to 2 days. She reported characteristic prostrating headache pain once per month. The examiner selected that her headache condition did not impact her ability to work, but did not explain this finding. A March 24, 2016 VA women's health record included the Veteran's report of a current headache that started "Saturday" when she woke up. She skipped church on Sunday, and Monday she took her Sumatriptan. The Sumatriptan made her feel "jittery" but her headache went away. A January 30, 2017 VA neurology record included the Veteran's report that Rizatriptan was working and she had been headache-free lately. She noted 3 headaches a week previously, that she attributed to "stress." It was suggested she start preventative migraine prescription medication, which she declined. A June 29, 2017 VA mental health record included that the Veteran felt she had "come a long way" in treatment. She continued to feel anxiety at times, but only around women who seemed particularly aggressive or have said hurtful things. She stated she had made a couple of new female friends since she had been in treatment. The provider noted the Veteran had made progress in treatment and suggested that it was "time to taper back session frequency and work toward termination." Her mood was reported as "happy," affect euthymic, and other mental status evaluation findings were normal. By July 20, 2017, the Veteran reported she had been "moody" for the past week due to a headache and that she was "frustrated that she could not get VA to give her 100 percent disability." She also talked about attending and singing at the funeral of one of her foster cousins the prior week. An August 16, 2017 VA neurology record included that Rizatriptan worked for the Veteran's headaches, but she still suffered headaches when "stressed out." She gave examples of headaches on the anniversary of deaths of family members. By November 2017, VA mental health providers had found that the Veteran's depression was in "partial remission." It was noted that she continued to "work out stressors on her own." She described her mood as "ups and downs, but good." The note included that she had the significant stressors of deaths in the family over the past few years and a son with substance abuse problems. On March 8, 2018, the Veteran reported she was "having anxiety again." She reported that during a recent meeting of deacons at her church she "felt panicky and had to go for a walk to calm down." She was serving as a deacon in her church, and usually when she attended deacons' meetings her husband was with her, but lately the women deacons decided to have some women-only meetings. She feels that being with the women in a circle reminds her of being sexually harassed (by two women) in service. It was suggested that she might not have had overwhelming anxiety if she had been on her prior higher dose of Venlafaxine, which she had recently decided to self-lower. Her mental status evaluation included that she was "a little tense talking about her anxiety." A March 26, 2018 VA neurology record noted the Veteran's headaches "come and go;" Rizatriptan "seems to work, but she still suffers headaches when getting stressed out." Her headaches were intermittent. She could awaken with a mild headache 3 days a week that may worsen. She described the pain as a throbbing pressure. She stated that lying in a quiet area and Sumatriptan may help. Her headaches were noted to be migrainous with a stress-related factor. On April 12, 2018, the Veteran reported that she had her "best women's meeting ever!" She felt proud of how she managed her anger toward another church member who she felt was demanding. She noted she spoke with another friend about the situation and waited until she was calm to respond. Her mental status examination was normal, with a "good" mood. The provider continued to note that her depression was "in partial remission." On June 7, 2018, private physician E.C. provided a narrative psychiatric evaluation. As described in greater detail in the 2019 Board decision, the evaluation was less probative than her ongoing mental health records given the significant discrepancies in the severity/content of her symptoms noted by Dr. E.C. compared to her monthly mental health records. Relevant to this decision, the June 2018 evaluation included that the Veteran reported experiencing "near-constant symptoms that interfered with her overall quality of life." According to the Veteran, she suffered problems with authority and supervision, marital discord, impulse control problems, trust issues, severe sleep issues, and an excessive need to provide protection to herself and her family. Notably, she had been married to her husband for 36 years, had four children, and had 15 grandchildren at that time. Yet, she stated that she had "been unable to have many meaningful relationships, since leaving the Army." She described her current relationships as "okay," but found it "more and more difficult to leave her house...she spends almost no time with anyone outside of family and that she stopped going to many family events." The Board notes VA therapy sessions revealed she saw her family frequently (including having grandchildren stay with her), went to birthdays/gatherings/baby showers and hosted Thanksgiving with family, attended speaking and singing engagements, attended church frequently (such that when she did not attend for two Sundays the pastor's wife called her to check in), had lunch with friends, found pleasure in shopping, etc. She noted her husband was her calming source, but that she felt emotionally "cold and withholding." She reported "poor communication and near-debilitating anxiety (at times)." She reported poor impulse control, anxiety, and the inability to effectively communicate. The Board notes that these statements are not supported by examples in the evaluation report. Given that she has served as a Deaconess, given sermons and talks at nursing homes, helped family member navigate parenting and employment issues, etc. it would appear she communicates effectively, and manages her anxiety and impulse control regularly. The report included that she had "great difficulty communicating with individuals effectively and appropriately...[which] cause[d] issues in the work environment with peers and supervisors." The Board notes that she worked for the school district for 15 years without any reprimands, and another 12 years part-time for a movie theater, working with the public, again without reprimands or being fired. She also reported that she enjoyed interacting with the public at her movie theater employment. Dr. E.C. noted that the Veteran had "few friends" and was "reclusive." She was mistrustful and suspicious of others and was noted to "rarely leave her house." She reported "intermittent inability to perform certain activities of daily living; i.e. grooming, showering on a regular basis, etc." However, when asked about her ability to complete daily tasks during her January 2019 Board hearing, the Veteran admitted that this was due to back pain and other physical impairments. Also, her frequent and ongoing VA treatment records always indicated good hygiene. Similarly, VA treatment records included her report of difficulty sleeping due to pain. On June 14, 2018, the Veteran reported to her VA therapist that she had a good birthday, and that she changed the party from something at her house to her favorite restaurant to see "who's a true friend" of the people she invited. Also noted she felt snubbed at a tea she attended and refused an offer when eventually invited to sit at a table with those who she felt had snubbed her. "Veteran is still somewhat quick to interpret intention/actions of others in a negative interpersonal light, but mood is stable." The Board notes that this is in sharp contrast to the private psychologist report dated the week prior which noted that the Veteran rarely left her home and was socially isolated. The Board finds the private psychologist's opinion regarding the Veteran's ability to obtain and maintain employment to be less than probative given the great number of discrepancies between his findings on examination and the overwhelming amount of mental health treatment records with contrary findings, including within a short period from the evaluation report. In October 2018, the Veteran again submitted a TDIU claim form. This time, she indicated that she was unable to follow substantially gainful employment due to the service-connected stress disorder. On December 11, 2018, the Veteran testified before Judge Parker regarding several service connection claims and the claim for TDIU. She testified that she could not stand for long due to her back pain. Regarding the claim for TDIU, the Veteran stated she was unable to work due to both physical and mental disorders, including that she did not work well with others, and did better on her own. Judge Parker asked her which psychiatric symptoms impacted her ability to work, to which she testified that she needed to "sit on the end pew at church" or next to her husband, that she would snap at her husband for no reason, had nightmares, and did not have a social life, though she was a deacon at her church. Regarding headaches, the Veteran testified that she did not have headaches every day, but had them once per week, and that they came when she was under pressure. On January 25, 2019, the Veteran testified before Judge Gunn regarding the psychiatric rating issue and TDIU claim, reporting that she could not be around a crowd of "females." She testified that she had submitted reports from private psychologists that she suffered from panic attacks once per month when she had deacon meetings, and she would have to excuse herself from the room. She described walking away because she was afraid that she had a "violent temper." She also argued she had memory problems because she forgot to pay her credit card once; the credit card company waved the fee because it was the first time it happened. Regarding the claim for TDIU based on psychiatric disability, the Veteran stated she was not able to work because she was afraid of "hurting people or hurting" herself, was better at working alone, and had trouble with having a female supervisor. When asked why she stopped working in October 2012, the Veteran stated that it was "mainly because [her] back was hurting so bad, then the mental part where [she] was told that [she] would have to stand upstairs and tear the tickets." When asked why she cannot work now, she stated that "because as soon as they tell [her she was] going to have to work in group cleaning or anything," she knows that she is "going to go off" and she did not want to hurt anyone. She reported she had been married for 37 years, with a good relationship with her husband, had good relationships with her children, and had "wonderful" relationships with her 15 grandchildren. When asked about needing help around the home, the Veteran stated that this was due to back pain. She stated that when she worked at the theater, she was given a chair for when she was in the ticket booth as an accommodation for the back pain. The July 2019 Board decision determined that the VA treatment records were more probative than the private psychologist evaluations, and, therefore, the symptoms and occupational impairments noted in those evaluations are also less probative when determining entitlement to TDIU. Ongoing treatment records from June 7, 2018 do not show the "total" social and occupational impairment for the 100 percent schedular disability rating that was nevertheless assigned by the RO for the service-connected psychiatric disorder. The Veteran has argued that she is unable to work due to the service-connected mental health disability because she has trouble getting along with others, has a "violent" temper (is afraid she would hurt others or herself), and also that her depression makes her unmotivated and anti-social/reclusive. As noted above, the Board does not find these statements to be consistent with the other histories and symptoms reflected in the ongoing treatment records. While the Veteran may find herself easily angered, she has shown to VA providers that she is capable of calming herself through various methods. She has reported one instance of anger expressed at a supervisor in all of the years of employment, and has denied that she was ever fired or disciplined during her periods of employment. She has also reported memory impairment and lack of motivation has psychological symptoms impacting her ability to work. There has been no indication that the Veteran was confused about the time or place of, and was able to report to, her therapy sessions consistently by herself. She was also frequently left in charge of her grandchildren, which would indicate that she has the mental wherewithal to care for children. She provided an example during her Board hearing of "memory impairment" in that she failed to pay a bill on time once, during the holiday season in December 2018, and that this failure to pay was forgiven by the company because she had always been on time paying in the past. Although the Veteran has some contentious relationships with some of the women in her officer's meetings at church, she has made friends with others, has been able to participate in choir, serves as a Deacon/Deaconess, and provides ministry to members of a nursing home once per month. From the period from 2012 to June 7, 2018 the Veteran suffered a large number of losses and suffered through some difficult journeys with her children (loss of housing, loss of jobs, incarceration, death of a friend's son, difficulties with the way some of her grandchildren are parented) while still frequently reporting "good" moods, full affects, and providing help and understanding to those in her life. On more than one occasion, her mental health provider suggested that her therapy sessions be decreased due the Veteran's mental health improvement. As addressed above, the inability to perform some activities of daily living have been attributed by the Veteran to her physical disabilities. Her SSDI records, as well as VA treatment records, include the Veteran's report that her hand/wrist, feet, hip, and back pain all prevented her from working. She stopped working in cleaning in 2005 due to a foot injury. She took a "settlement" from the school district following the injury. Additionally, her VA mental health records included the Veteran's report that she enjoyed working, that working helped her to manage her psychiatric symptoms, that she missed working, and that she felt her psychiatric symptoms had worsened as a result of her being unable to work due to physical disabilities. The Board notes that the Veteran serves as a Deaconess at her church, is involved in the women's ministry, participates in and give performances with a choir, provide talks/ministry to a nursing home once per month, frequently cares for her grandchildren (and even attempted to be the full-time, 12 hours a day, caregiver for an infant grandchild in 2019), has large social gatherings with her family, hosts holiday meals for her children and grandchildren (there are at least 16 grandchildren as of the latest records), socializes with friends (meals, gatherings, talking on the phone, walking) all without any incidents wherein her mental health condition has negatively affected her standing or abilities to further participate. The Board also notes that her ongoing mental health records do not indicate that the headaches have been interfering with her life, service, or social schedule. She has had instances of anxiety where she has been able to self-soothe and self-correct, and she has continued her positions within her community. Throughout the period on appeal she has been a constant resource for her family for housing, childcare, emotional support, advice-giving, etc. without any indication of social impairment. There are limited treatment records related to the migraine headaches. The Veteran is receiving VA neurology treatment for the headaches, which are described as migraines aggravated by stress. She was able to participate in two hearings during which she reported having a headache during the hearing. She also sought treatment for a migraine the day prior to her VA headache examination. Although she reported monthly prostrating headaches during the examination, the treatment records noting treatment on multiple occasions indicate that the headaches are infrequently severe enough for her to wish to treat them with her prescription medication, and that she did not wish to have prophylactic medication. During the period from January 27, 2014 to June 7, 2018, the Veteran reported monthly to more than weekly headaches with nausea, light and sound sensitivity, and throbbing head pain. Although the Veteran is in receipt of ratings for her psychiatric and headache disabilities that appear to be greater than the severity shown in the ongoing treatment records, the Veteran's disabilities result in anxiety, anger, feelings of insecurity/low self-worth, and stress wherein the stress aggravates her migraine headaches. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the combination of the headache and psychiatric symptoms and functional impairments render the Veteran unable to maintain substantially gainful employment for the period from January 27, 2014 to June 7, 2018. VA has a well-established duty to maximize a claimant's benefits. This duty to maximize benefits requires VA to assess all of claimant's disabilities to determine whether any combination of disabilities establishes entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114. Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). In this case, the grant of TDIU for the period from January 27, 2014 to June 7, 2018 is based on the combined impact of all the service-connected psychiatric and headache disabilities. The Veteran has not asserted, and the evidence does not suggest, that a TDIU is warrant based on only one service-connected disability. As such, a claim for SMC(s) is not raised. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals J. PARKER Veterans Law Judge Board of Veterans' Appeals E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. H. Stubbs, 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.