Citation Nr: 21072521 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 17-20 216 DATE: December 3, 2021 ORDER An initial disability rating in excess of 50 percent for the service-connected posttraumatic stress disorder (PTSD) is denied. A total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, is granted. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's service-connected PTSD was manifested by an overall disability picture no worse than occupational and social impairment with reduced reliability and productivity; his overall disability picture did not more nearly approximate 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 ideations; 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. 2. The Veteran's service-connected disabilities preclude him from securing and following gainful employment given his education and work history. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 50 percent for the service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a TDIU have been met for the period on appeal. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from August 2011 to July 2014. This matter is before the Board of Veterans' Appeals (the Board) on appeal from a September 2014 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The rating decision, inter alia, granted service connection for PTSD (claimed as PTSD due to MVA and sleep disturbance) and assigned an initial 30 percent disability rating effective July 29, 2014. The Veteran's Notice of Disagreement (NOD) was received in December 2014. In a March 2017 rating decision, the RO increased the initial PTSD rating to 50 percent from July 29, 2014, the effective date of service connection. The Statement of the Case (SOC) was issued in March 2017, and the Veteran's VA Form 9, substantive appeal to the Board was received in March 2017. In February 2019, the Board remanded the claim for additional development of the record, along with an inferred claim for a TDIU that had been reasonably raised by the record as part and parcel of the increased rating claim on appeal. Rice v. Shinseki, 22 Vet. App. 447, 45354 (2009). 1. Entitlement to an initial disability rating in excess of 50 percent for the service-connected PTSD. The Veteran contends that his PTSD is worse than currently rated. The Veteran's PTSD is rated as 50 percent disabling from July 29, 2014 under 38 C.F.R. § 4.130 DC 9411. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Separate diagnostic codes identify the various disabilities. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to assign to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, as here, the current appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased-rating claim in which distinct time periods during the appeal period reflect differing levels of severity. Hart v. Mansfield, 21 Vet. App. 505 (2007). As with other psychiatric disorders, the criteria for rating PTSD are based on the General Formula for Mental Disorders, found at 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, a 50 percent evaluation is warranted where there is 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; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is 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 work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation requires 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; and memory loss for names of close relatives, own occupation, or own name. Id. Ratings assigned under the General Formula for Mental Disorders must be based on a holistic analysis that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10 (2017); 38 C.F.R. § 4.130. The symptoms listed in the General Rating Formula are examples, not an exhaustive list and it is not required to find the presence of all, most, or even some of the enumerated symptoms. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate rating to be assigned for a service-connected mental disorder, the focus is on how the frequency, severity, and duration of the symptoms affect the Veteran's occupational and social impairment, rather than on an absence of particular symptoms listed in the schedular criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The Board must consider 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. While VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment. Id. In November 2013, the Veteran underwent a VA examination for his claim. The Veteran reported being single and living on base, where his sister was also stationed. He reported seeing his sister and nephew a lot and hanging out with two close friends. The Veteran reported seeking mental health treatment after having really bad anxiety and not being able to sleep. He reported taking Zoloft and Trazadone along with a medication to decrease nightmares. He reported the medications not really helping that much. Under PTSD symptoms, he was noted to have anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, and difficulty in adapting to stressful circumstances, including work or a worklike setting. He was deemed capable of managing his own financial affairs. The VA examiner concluded that the Veteran met the criteria for a DSM-4 PTSD diagnosis and had symptoms of automobile phobia due his in-service stressor, and depression. It was also noted that his sleep disorder was a symptom of his PTSD. The VA examiner concluded that the Veteran's PTSD manifested 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. A May 2015 VA mental health intake note indicates that the Veteran had a history of depression and PTSD. It was noted that the Veteran appeared to live in a safe and suitable environment with his family with whom he had a supportive relationship. The Veteran was screened as low risk for suicide. Under mental health status exam, it was noted that the Veteran was polite, cooperative, his speech normal, and his mood normal. The Veteran denied suicidal or homicidal ideations. The Veteran did not report any sleep concerns or issues. He was noted to be oriented, his concentration and memory appeared normal. His thought process was clear and logical, with his judgment and insight fair. A June 2015 VA mental health intake note indicates that the Veteran reported nightmares every night, depression, and insomnia. He denied suicidal ideations or past attempts. He reported taking not taking his prescribed Prozac and taking Prazosin only sometimes. The Veteran reported sometimes seeing things move. He reported his symptoms as little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling and staying asleep, feeling tired and having low energy, poor appetite or overeating, feeling about self, trouble concentrating, and moving and speaking so slowing that other people could have noticed. The Veteran denied thoughts of suicide or harming others. Other symptoms were listed as panic attacks, anger problems, memory problems, and sleep problems. The Veteran's mental health status examination indicates that he was well groomed and appropriately dressed, made eye contact, had normal speech, was alert and oriented. His mood was depressed. The Veteran was scheduled to begin therapy through the VA. In June 2015, the Veteran underwent an evaluation for social security disability. He was diagnosed with PTSD and deemed a reliable historian. The Veteran reported being in a car accident in service and having a TBI. His chief complaint was PTSD, depression, anxiety, panic attacks, and somatic symptom disorder. The Veteran reported having disproportionate and persistent thoughts about the seriousness of his symptoms, high levels of anxiety about his symptoms, and spending excessive time and energy devoted to his symptoms and pain management. He reported depression beginning in January 2013 and reduced sleep with average of 2 to 3 hours of broken sleep in a 24-hour period. He also reported reduced interests, energy, concentration, and interest in sex. He reported sadness, and auditory and visual hallucinations beginning in October 2012. The Veteran reported seeing objects move when he is awake at least once a day and hearing voices and whispers at least once per day. He denied current suicidal or homicidal ideations and denied having a history. The Veteran's PTSD symptoms were listed as intrusive memories and dreams, recurring flashbacks, intense psychological or physiological reactivity to internal or external cues, avoidance, detachment, inability to recall details, negative beliefs about self and others, diminished interest or participation, detachment, difficulty sleeping, difficulty concentrating, irritability, anger, hypervigilance, and exaggerated startle response. He was noted to have anxiety and panic attacks which occur two times per month lasting about 3 minutes, precipitated by large crowds or lack of control. The Veteran reported seeing a psychologist twice per week since 2013 and not having any psychiatric hospitalizations. He was noted to take Prozac and other medications for his psychiatric disabilities. Upon examination, it was noted that the Veteran was casually dressed and well groomed. The Veteran used a cane for limping for both legs. The Veteran was noted to be open, friendly, and cooperative. He maintained eye contact and demonstrated no signs of anxiety while having a good frustration tolerance. His speech and thought process were noted to be normal. The reported noted that the Veteran's memory was slightly limited. However, the report itself notes that the Veteran was able to recall every single item asked of him. His concentration and abstract thinking were noted to be normal upon examination. It was noted that the Veteran required assistance for bathing, grooming, cleaning, and transportation. It was noted that he is able to cook, feed himself, and manage his finances. He was noted to occasionally socialize with friends and family. The Veteran was diagnosed with PTSD, MDD, GAD, panic disorder, and somatic symptom disorder. His MDD and somatic disorder were noted to be severe. The report goes on to state that the Veteran is currently in counseling and appears to be receiving medication management. It was noted that the Veteran appears generally able to reason but is struggling to make occupational, personal, and social adjustments independently. It was noted that the Veteran's symptoms may improve, but that any improvement is fully contingent upon adherence to and the efficacy of available resources. An August 2015 VA treatment note indicates that the Veteran did not attend final week of group therapy and did not answer the provider's phone calls after cancelling therapy. A September 2015 new patient VA mental health note indicates that the Veteran was seen for intake for PTSD therapy. It was noted that he has had many PTSD treatments in the past but never finished a protocol. A December 2015 VA mental health intake evaluation indicates that the Veteran presented with irritability, lack of trust, keeping to himself, and needing to control things around him. As an update from his last evaluation, it was noted that he was most concerned about chronic pain, concentration issues, lack of trust, and isolation. The Veteran was noted to be alert, oriented, appropriately dressed and groomed, with normal and coherent speech, good eye contact, dysthymic mood, and affect with restricted range, congruent to mood. His thought process and content were normal, with no hallucinations, delusions, paranoia, or suicidal or homicidal ideations. His memory appeared grossly intact. He was noted to have good insight and judgment. It was noted that the Veteran chose a treatment plan but would not start it as he was pending birth of his child. An April 2016 VA mental health treatment note indicates that the Veteran began therapy. His mental health status check was the same as before, with no hallucinations, delusions, or suicidal/homicidal ideations. He reported concentration concerns and noted that he was taking care of his 4-month-old baby. His May 2016, June 2016, July 2016, August 2016, and September 2016 VA treatment notes all contained similar findings and reports. In July 2016 the Veteran reported feeling much better but struggled with sleep, relationship stress, and obsessive thoughts. In September 2016, the Veteran reported a rough week but reported no delusions and no suicidal/homicidal ideations. He reported continuous issues with sleep, irritability, safety and control, and depression. However, he requested that he stop therapy and monitor his own symptoms. In November 2016, the Veteran's parents submitted statements. His mother indicated that the Veteran used to be an overachiever and was not the same when he returned from service. She indicated that she talks to him twice per day on face time, and that he does not trust anyone except her and his father, that he has nightmares, trouble sleeping, goes days without showering, does not leave the house or open his blinds. She also noted that the Veteran has a hot temper and impaired impulse control, tending to throw things and refusing to be touched. It was also noted that the Veteran's communication is slow and he forgets things. The Veteran's father indicated that since returning from service, the Veteran is extremely anti-social, angry, and fatigued. He also indicated that the Veteran went days without brushing his teeth or showering, and that his personal appearance has been neglected. The Veteran's father stated that he talks to the Veteran every date over Face Time and that the Veteran stays to himself and barely maintains a relationship with his wife. A December 2016 VA treatment note indicates that the Veteran once again attempted to engage in treatment and reported that he has had over 9 mental health providers and quit each time. The Veteran had concerns over expectations of therapy, accommodation of his particular needs, irritability, and lack of short term memory. The Veteran's mental health status check was the same as before, with the Veteran being well groomed, oriented, having normal speech and eye contact, intact memory, and no hallucinations, delusions, paranoia, suicidal/homicidal ideations. The Veteran's VA treatment records indicate that he participated in therapy through April 2017 with the same findings. A February 2017 Disability Benefits Questionnaire by H.H., a licensed psychologist, indicates that the Veteran resides with his wife and their infant son, but keeps his struggles to himself. He was noted to be socially isolated and withdrawn. It was noted that the Veteran's last job was the military and that he began receiving disability in 2016 for his physical and mental difficulties. He was not noted to have a TBI. It was noted that the Veteran did not take his medication for mental health due to fear of side effects. It was also noted that the Veteran sees a VA psychiatrist every six months, and a VA psychologist weekly, and denies participation in VA group therapy. The Veteran denied legal, behavioral, or substance abuse history. His symptoms were listed as depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, impaired impulse control, such as unprovoked irritability with periods of violence, persistent delusions or hallucinations, neglect of personal hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. H.H. noted that the Veteran details great ongoing difficulty with his symptom pattern and is unable to enjoy the simplest of activities. Upon mental status exam, the Veteran's attention and concentration appeared normal. The Veteran reported memory problems, including remembering basic information. The Veteran's speech flow was normal, although it was noted that he was brief with the information that he offered. His thought content was normal and organization of thought was goal oriented. The Veteran reported overt hallucinations. His judgment was noted to be average, mood anxious, affect restricted. It was noted that the Veteran was suspicious and vigilant, and unsure of himself. It was also noted that the Veteran's wife assisted him with finances. Under employability review, H.H. noted that the Veteran cannot sustain the stress from a competitive work environment, and cannot be expected to engage in gainful activity due to his PTSD. The Veteran reported not getting enough sleep and being fatigued nearly every day, which would be a safety issue in the work force. It was noted that the Veteran had trouble maintaining a steady mood, which causes problems in his social and work life. The Veteran reported struggling with ongoing anxiety and trust issues. H.H. concluded that employers note higher distractibility, absenteeism, and emotional turmoil as inappropriate in the workplace. It was noted that the Veteran's parents submitted a November 2016 letter reporting that the Veteran returned from service a different person and suffered from fatigue, isolation, neglect of personal hygiene, short temper, impaired impulse control, irritability, periods of violence, difficulty establishing and maintaining relationships, and memory issues. H.H. cited studies showing that PTSD leads to occupational impairment and concluded that the Veteran's PTSD symptoms are preventing him from maintaining substantially gainful employment. H.H. indicated that the Veteran's PTSD manifests in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. H.H. also submitted a functional capacity evaluation noting that the Veteran would miss 3 or more days per month due to mental problems, would need to leave the workplace early 3 or more days per month because of mental problems, would not be able to stay focused for at least 7 to 8 hours per day for at least 3 days per month, and would respond in an angry manner but would not actually become violent more than once per month when subjected to normal pressure. A June 2017 vocational opinion from S.B., a vocational consultant indicates that the Veteran's records were reviewed, including H.H.'s February 2017 report and that the Veteran has not worked since discharge due to his physical and mental impairments. S.B. summarized the Veteran's medical records, including the November 2013 VA examination report, the Veteran's VA treatment records, and H.H.'s report. S.B. noted that they reviewed the Veteran's family statements but did not find them relevant as to the Veteran's employability. S.B. went on to state that according to research, most employers allow for no more than 8 days of absence per year depending on the industry, and that the Veteran is expected to miss more time than that based on his reported symptoms. S.B. noted that the Veteran's social security records show that he has hallucinations, problems concentrating, irritability, is uncomfortable in public, and struggles to make occupational and social adjustments independently. S.B. concluded that the Veteran is precluded from performing work at a substantial gainful level due to the severity of his service-connected disabilities. A November 2018 VA treatment note indicates that the Veteran has PTSD but is not on pharmacotherapy. It was noted that he was seen in 2017 before decision to cease therapy, and that he has a supportive home environment with wife and children. His symptoms were noted to be stable. It was noted that he still endorsed some nightmares and no suicidal/homicidal ideations. A June 2019 VA treatment note indicates that the Veteran has a history of PTSD, but is unwilling to do medication management or work with any behavioral staff. An April 2020 VA covid shelter in place order note indicates that a VA provider called the Veteran to check on his wellbeing. The Veteran reported doing well with his biggest issue being that his glasses are broken. It was noted that there were no elevated concerns regarding the Veteran. An August 2020 VA primary care note indicates that the Veteran continues to refuse to take medication for his psychiatric symptoms but is willing to participate in therapy. He was referred to VA mental health. An August 2020 VA behavioral screening note indicated that the Veteran was assessed to determine the urgency of his mental health needs. It was noted that he tried therapy in the past with poor results, and that he was open to individual and group therapy but will not be taking any medications. The Veteran indicated that he prefers phone appointments as he is the primary caretaker of his two children. He reported no history of assault or domestic violence, but reported a history of psychosis, with seeing things in his peripheral vision and hearing things when trying to sleep. The Veteran's provider noted that these symptoms more aligned with hypervigilance and not psychosis, with the Veteran not having any imminent risk to harm self or others. It was noted that the Veteran was an appropriate candidate for outpatient treatment. A September 2020 VA mental health comprehensive history and assessment indicates that the Veteran has trouble sleeping, and suspected to have sleep apnea, although not on CPAP. The Veteran reported having bad anxiety, memory loss, and problems on the job. He also reported being the main caregiver of his children and having a supportive wife. He reported being the closest to his immediate family and having no serious financial issues or concerns. A September 2020 VA mental health treatment note indicates that the Veteran reported a lot anxiety, never feeling rested, having sleep problems, lack of energy, irritability, depression, avoidance behaviors, problems with relationships and problems with his job that act as potential barriers to achieving and maintaining his self-identified life. Under treatment plan, it was noted that the Veteran is to attend bi-weekly sessions for 12 months and complete screening tools to track the changes in his symptoms. An October 2020 VA treatment note indicates that the Veteran cancelled his most recent appointment due to a scheduling conflict but continued to have irritation and anxiety and was willing to continue treatment. In November 2020, the Veteran requested, and was assigned to a new mental health provider. A December 2020 VA treatment note indicates that the Veteran was seen for therapy and his mental status examination results continued to be the same. He reported anxiety and decision making problems, impulsivity, hypervigilance when driving, and anxiety due to problems with his parents. He reported using grounding techniques to manage his anxiety, indicated that he takes his child to school every day which sometimes makes him nervous, but that he handles his symptoms well. A January 2021 VA mental health treatment note indicates that the Veteran reported increased anxiety ahead of therapy sessions. The Veteran reported feeling ok, but having bursts of emotion and raising his voice around children, which is followed up with a conversation. His mental health status exam results remained the same with normal speech and thought content. A February 2021 VA mental health note indicates that the Veteran is planning on starting college in the summer. It was noted that his pain medication helps manage his irritability. He reported being in a good space, requested to stop therapy, and indicated that he will contact the provider when he wants to resume treatment. The Veteran's June and July 2021 VA treatment notes indicate that his PTSD is stable with no medications, and that the Veteran feels supported by his spouse, and is thus not followed for his psychiatric symptoms. Based on a careful review of the entire record, the Veteran's overall disability picture is manifested by symptoms which fall squarely within the criteria for the assignment of a 50 percent disability rating for the entire period on appeal. Great probative weight is placed on the Veteran's VA treatment records in this case, as the VA therapists are trained in the mental health field and competent to report the overall state of the Veteran's mental health. Throughout the period on appeal, the Veteran's PTSD symptoms include anxiety, depression, nightmares, occasional but not sustained flashbacks, emotional outbursts, avoidance, isolation, hypervigilance, sleep disturbance, difficulty establishing and maintaining relationships, and exaggerated startle response. While some of these symptoms remained constant throughout the period on appeal, the record shows that the Veteran's symptoms stabilized to the point where he did not feel that they required treatment. His November 2018 VA treatment note indicates that his symptoms were stable but that he still endorsed some nightmares. His June and July 2021 VA treatment notes indicated that his PTSD is stable, that he feels supported by his spouse, and that as a result he is not seeking psychiatric help. The evidence does not show that the Veteran's symptoms are of the type and degree contemplated by the criteria for a 70 percent disability rating at any time during the period on appeal. The record does not show that the Veteran had suicidal or homicidal ideations, obsessional rituals, illogical speech, near-continuous panic or depression, impaired impulse control, memory problems, spatial disorientation, inability to establish or maintain effective relationships; or, symptoms of a similar type and severity. At no time has the evidence shown that the Veteran's PTSD symptoms resulted in disorientation to time, place, or person. He is not out of touch with reality, or shown to experience persistent delusions or hallucinations, and he consistently denied suicidal or homicidal ideation. Thus, the extent of his impairment has not been shown by the competent medical evidence of record to be that which required a 70 percent or higher rating at any time during the period on appeal. In short, the Veteran's overall disability picture is not manifested by occupational and social impairment with deficiencies in most areas. Accordingly, the assignment of the next higher 70 percent rating is not warranted. With respect to hallucinations, the Veteran provided conflicting reports. During, the June 2015 evaluation for social security disability, the Veteran reported beginning to have auditory and visual hallucinations in October 2012. However, he did not report this during the November 2013 VA examination. He also continued to deny visual and auditory hallucinations to his VA providers (including in December 2015, April 2016, and onward). The Veteran also reported overt hallucinations during his private February 2017 evaluation. However, during this time, he was denying having hallucinations during his VA providers. Finally, in an August 2020 VA treatment note, the Veteran reported seeing things out of his peripheral vision and hearing things as he goes to sleep. His provider attributed this to hypervigilance as opposed to psychosis. Thus, the evidence does not show that the Veteran experienced sustained hallucinations. While the Veteran reported overt hallucinations during the February 2017 evaluation, his reports are contradicted with the reports he provided in his VA treatment records. Moreover, the Veteran's reports of hallucinations are not endorsed by his treating providers. In other words, the Veteran reports that he has hallucinations, but the Veteran's mental health providers have not indicated that any hallucinations have been observed on mental status examination. The Veteran's VA treatment records are afforded greater probative value as the records were created in the process of providing the Veteran with medical treatment. These records contain a singular complaint of hallucinations which has been attributed to hypervigilance as opposed to psychosis or being out of touch with reality. With respect to memory and concentration, the Veteran asserted problems with both. During the February 2017 private evaluation by H.H., he asserted being unable to remember basic information. However, his VA treatment records and evaluations show that his memory and concentration appeared intact. For example, during his June 2015 social security disability evaluation, the Veteran reported limited memory, but was able to recall very single item asked of him. His VA treatment records routinely state that his memory is intact, and his concentration is normal. His VA treatment records likewise do not contain reports of frequent panic attacks. The Veteran's parents submitted November 2016 statements outlining the Veteran's symptoms. However, these statements are not afforded probative values. They are contradicted by the Veteran's VA treatment records. The Veteran's parents attested to speaking to the Veteran on a daily basis and to him not keeping up with hygiene, having problems with his wife, not leaving the house, and having memory and communication problems. However, the Veteran's VA treatment records contain consistent reports that the Veteran's relationship with his wife remained strong and supportive, that he continues to take his children to school every day and leaves the house, and that there were no problems with his hygiene. Finally, the Veteran's psychological evaluations and screenings consistently showed that his memory was intact, and his communication was adequate. These results were consistent despite the Veteran reporting otherwise. Moreover, the Veteran's statements are not afforded probative value because the Veteran indicated that he stopped having a relationship with his parents and has not communicated with them. Next, the February 2017 private evaluation by H.H. and the subsequent occupational opinion by S.B. both suggest that the Veteran's PTSD is more severe than what is represented in his VA treatment records and the November 2013 VA examination report. H.H. indicates that the Veteran's PTSD manifests in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. H.H. also indicated that Veteran's PTSD requires him to miss 3 or more days per month, leave the workplace early at least 3 days per month, unable to concentrate for 7 to 8 hours per day for at least 3 days per week, and would respond in angry manner but not resulting in violence more than once per month when subjected to normal pressure. H.H. also indicated that the Veteran experiences impaired impulse control, such as unprovoked irritability with periods of violence, persistent delusions or hallucinations, neglect of personal hygiene, intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, and requires help with his finances. These conclusions are not supported by adequate rationale and are wholly contradicted by the record. As noted above, the Veteran did not experience persistent delusions or hallucinations. There is also not indication anywhere in the record that he is unable to perform his daily activities of living, tend to his hygiene, or required help with his finances. To the contrary, the Veteran's was noted to be adequately dressed and groomed throughout the period on appeal. He also denied needing help with his finances. While he may require some help with daily activities due to his physical disabilities, there is no indication that his PTSD precludes him from cooking or feeding himself, upkeeping his hygiene, and other daily activities. H.H.'s conclusions that the Veteran will require at least 3 work absences per month due to PTSD are not supported by the record as the Veteran has indicated that he has not been employed since discharge. Also, as discussed below, the Veteran has not been compliant with his psychiatric treatments, making the assertions that he would require workdays for treatment completely speculative. Additionally, while the Veteran reported anger and irritability problems, there is no indication in the record that these problems escalated to the point of violence. The Veteran routinely confirmed no history of assaults, no criminal history, and no domestic violence. The reports from his family members did not include any safety concerns. Most importantly, the evidence does not show that the Veteran's PTSD symptoms are of such frequency and severity, as to preclude the Veteran from maintaining personal relationships. The February 2017 private evaluation from H.H. indicates that the Veteran's PTSD causes a social impairment with deficiencies in most areas, including school, family relations, and judgment. This is again contradicted by the Veteran's VA treatment records. These records show that the Veteran's wife remained supportive, and that the Veteran is the primary caregiver to his two children, including getting them to school on a daily basis. Moreover, the records show that the Veteran feels supported by his wife to such degree, that he does not feel the need to participate in therapy to manage his PTSD symptoms. The Veteran reported some problems related to his parents but there is no indication that his family relations suffered as a result of his PTSD. To the contrary, the Veteran's ability to acknowledge and rely on his wife's support, as well as continued commitment to provide adequate care for his children while refusing to take any prescribed medication for his symptoms illustrates that his symptoms are not of such severity as to preclude his ability to maintain personal relationships. Given that the probative medical evidence of record contradicts the conclusions in the June 2017 private evaluation by H.H., the report is not afforded probative value. Because the June 2017 vocational opinion from S.B. is based largely on H.H. February 2017 report, all portions of S.B.'s report dealing with the Veteran's PTSD likewise are not afforded probative value. In essence, the evidence shows that the Veteran does have social and occupational impairments due to his PTSD symptoms. However, the evidence does not show that the Veteran's symptoms are of such severity and frequency as to manifest in occupational and social impairments with deficiencies in most areas. Notably, the evidence illustrates that the Veteran is able to provide full time care for his two young children, is supported by his wife with whom he appears to have a strong relationship and continues to manage his psychiatric symptoms without medical treatment. The Veteran's VA treatment records noted that sometimes he is anxious taking his child to school every day and that sometimes he raises his voice at his children. These reports are followed up with notations that despite these struggles, the Veteran is able to take his child to school every day and is able to have a conversation with his children after he raised his voice at them. In other words, while the Veteran does suffer from psychiatric symptoms, which do cause him to struggle, these symptoms are not of such severity as to interfere with his ability to provide full time care for two young children, maintain a supportive relationship with his wife, and manage his symptoms without medical treatment. Finally, there is ample evidence of the Veteran's consistent refusal to comply with medicinal treatment and therapy for his PTSD. The November 2013 VA examination report indicates that the Veteran was prescribed and taking Zoloft and Trazadone without much help, and participated in regular therapy with the VA. He also appeared compliant with his medications during the June 2015 social security disability evaluation. Then, the September 2015 VA treatment note indicates that the Veteran never finished a single therapy protocol, the February 2017 evaluation noted that the Veteran refused to take his medication due to fear of side effects, and the June 2019 VA and August 2020 VA treatment notes indicate that the Veteran refused to take any medications prior to even starting therapy. As Veteran himself has pointed out, it does not appear that he has ever finished a recommended therapy regimen. Despite noncompliance with medication and noncompliance with therapy treatment, the Veteran's VA treatment records contain consistent reports that his PTSD is stable with support of his family and grounding techniques. In this case, the evidence of the Veteran's noncompliance with psychiatric treatment, in combination with reports that his symptoms are stable, and he provides full time care for two young children, further illustrates that his PTSD is not of such severity as to warrant a 70 percent disability rating. As the preponderance of the evidence is against the claim for a rating in excess of 50 percent for the service-connected PTSD, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Entitlement to a TDIU due to service-connected disabilities. The Veteran contends that the combination of his service-connected disabilities precludes him from obtaining and maintaining gainful employment considering his education level and work history. 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. Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to the Veteran's age or the impairment caused by any nonservice-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). A TDIU 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. The service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue will be addressed in both instances. 38 C.F.R. § 4.16(a),(b). For consideration of a schedular TDIU, if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). The Veteran's service-connected disabilities include PTSD, rated as 50 percent disabling from July 29, 2014; left shoulder strain, rated as 20 percent disabling from July 29, 2014; lumbar degenerative disc disease (DDD), rated as 10 percent disabling from July 29, 2014; left knee degenerative joint disease, rated as 10 percent disabling from July 2019, 2014; temporomandibular joint disorder (TMJ), rated as 10 percent disabling from July 29, 2014; left hip strain, limitation of extension, rated as 10 percent disabling from July 29, 2014, then as 100 percent disabling under 38 C.F.R. § 4.30 from July 6, 2021, and as 10 percent disabling from October 1, 2021; left hip strain, limitation of abduction, rated as 10 percent disabling from October 11, 2021; left hip strain, limitation of flexion, rated as noncompensable from July 29, 2014; left knee scar, rated as noncompensable from July 29, 2014; and left hip scar, rated as noncompensable from July 29, 2014. The Veteran's total disability rating was 70 percent from July 2014, 100 percent from July 6, 2021, 70 percent from October 1, 2021, and 80 percent from October 11, 2021 onward. The Veteran's disability ratings meet the schedular threshold percentage requirement for consideration of a schedular TDIU for the period on appeal because during the entire period on appeal, the Veteran has had a combined disability rating of at least 70 percent, with at least one disability (his PTSD) rated at 50 percent. Thus, the only remaining question is whether the Veteran's service-connected disabilities precluded all forms of substantially gainful employment consistent with his education and work history. The record with respect to the Veteran's PTSD is discussed above. In November 2013, the Veteran underwent VA examinations for his back, knee, shoulder, hip, scars, and TMJ. With respect to TMJ, the Veteran reported flare ups, brought on by hard food, excessive chewing, opening wide, all causing increased pain. The VA examiner noted that the Veteran's TMJ did not have an impact on his ability to work. With respect to the Veteran's back, it was noted that it is aggravated by prolonged positioning (more than 2 hours), walking (more than 2 miles), crouching, and any positions that add compression to the spine. The November 2013 VA examiner noted that the Veteran's back did not have an impact on his ability to work. With respect to the Veteran's knee, it was noted that the Veteran's disability was aggravated by any type of movement, walking for 2 miles, prolonged positioning, and caused weekly moderate flare ups. The November 2013 VA examiner noted that the Veteran would benefit from an occupational role allowing for limitations in movement. With respect to shoulder, it was noted that the Veteran's disability was aggravated by lifting heavy objects or putting weight on his shoulders. The Veteran reported mild daily pain and flare ups, with increased pain lasting 1 to 2 hours. The VA examiner noted that the Veteran's shoulder disability did not have an impact on his ability to work. A May 2016 decision from the Social Security Administration indicates that the Veteran has a status post femur fracture, bilateral knee patellofemoral syndrome, PTSD, MDD, GAD, panic disorder, and a sleeping disorder and was rendered disabled. As noted above, a June 2017 private vocational opinion from S.B. indicates that the Veteran's service-connected disabilities preclude him from maintaining employment. In addition to the aforementioned portions of the opinion that dealt with PTSD, S.B. summarized the Veteran's VA treatment records and examinations with respect to all of his service-connected disabilities. S.B. concluded that the Veteran's disabilities present a combination of emotional and physical limitations, which make it difficult for the Veteran to sustain work. S.B. also concluded that the Veteran is totally and permanently precluded from performing work at a substantial gainful level due to his service-connected disabilities. The Veteran's October 2020 VA Form 21-8940 indicates that he was last employed full time in July 2014, which was the United States Air Force. The Veteran's highest level of education is listed as high school. It was noted that prior to service, the Veteran had one part time job as a kitchen aid at a hospital for 2 years. The Veteran's October 2021 hip VA examination report indicates that the Veteran's service-connected left hip disability causes pain and limitation of motion. He was noted to have severe daily flare ups that last hours and are only temporarily suppressed by pain medication. With respect to functional impact, the VA examiner noted that the Veteran is unable to stand for more than 5 minutes, walk for more than 14 of a mile, run, or walk a flight of stairs. It was noted that his disability caused nightly sleep disturbance. Based on the above, the evidence supports the finding that the Veteran is unable to obtain or maintain gainful employment due to a combination of his service-connected disabilities. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) ("neither the statute nor the relevant regulations require the combined effect [of disabilities] to be assessed by a medical expert"). The question of whether a Veteran is capable of substantial gainful employment is not a medical determination, it is an adjudicatory one. Geib, 733 F.3d at 1354. The weight of the competent and probative evidence of record reflects that the Veteran's service-connected disabilities preclude most forms of substantially gainful employment based on his education and employment history. At the outset, the Veteran's education and employment history presents limitations. The Veteran has a high school diploma, and his work experience consists of part time kitchen aid work and active-duty military. Thus, it is likely that even prior to considering the functional limitations of the Veteran's service-connected disabilities, he would require further education or job training before he is able to secure gainful employment. Given his limited education and work experience history, it is likely that the Veteran will only be able to obtain entry-level or labor-intensive jobs. In this case, the evidence shows that the Veteran will not be able to perform job physical or labor-intensive job duties. The October 2021 VA examination report indicates that the Veteran is unable to stand for more than 5 minutes, walk for more than 14 of a mile, run, or walk a flight of stairs due to his service-connected hip disability. The November 2013 VA examination report indicates that the Veteran would benefit from a sedentary work environment. Accordingly, the record shows that the physical limitations from the Veteran's service-connected disabilities preclude him from obtaining any labor-intensive position. With respect to the Veteran's PTSD, the evidence shows that he is irritable, anxious, withdrawn, depressed, hypervigilant, and suffers from sleep disturbances. While there is no indication that the Veteran's aggression raises to the level of violence, it is clear that the Veteran struggles around crowds and people. As such, it is unlikely that he will be able to function in any work setting that requires him to be around people, including coworkers, supervisors, and customers. This precludes all customer service-oriented positions, as well as positions that require regular contact with co-workers. Thus, the evidence shows that the Veteran's PTSD symptoms preclude all employment requiring the Veteran to work with customers and/or co-workers. However, given the rise in opportunities for full-time telework as a result of the Covid-19 pandemic, there is more potential for gainful employment in a solitary setting with limited interaction with co-workers. Thus, the PTSD, alone, is not shown to preclude all forms of gainful employment, given his family relationships, and his ability to communicate effectively with his doctors and mental health providers. (Continued on the next page) In sum, the Veteran's service-connected disabilities present both physical and mental limitations. His physical limitations preclude all forms of labor-intensive positions, or any employment that requires prolonged standing or sitting. His service-connected PTSD precludes employment around people, including customers and co-workers. Finally, the Veteran's education and work history are extensively limiting, given that the Veteran has a high school degree and no full-time job experience outside of the military. Accordingly, given the limitations of the Veteran's service-connected disabilities along with his education and work history, it is more likely than not that he is unable to obtain and maintain full time employment. As the Veteran's service-connected disabilities render him unable to obtain and maintain full time employment, entitlement to a TDIU is warranted for the entire period on appeal. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kuksova, Kseniya 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.