Citation Nr: 21072574 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 16-62 208 DATE: December 3, 2021 ORDER An evaluation of 70 percent, but no higher, for an acquired psychiatric disorder, to include depressive disorder and post-traumatic stress disorder (PTSD), is granted for the period on appeal prior to May 1, 2019. Entitlement to an evaluation in excess of 70 percent for an acquired psychiatric disorder, to include depressive disorder and PTSD, is denied for the period on appeal beginning May 1, 2019. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted for the period on appeal prior to May 1, 2019. FINDINGS OF FACT 1. During the period on appeal prior to May 1, 2019, the Veteran's acquired psychiatric disorder was manifested by psychiatric symptomatology resulting in occupational and social impairment with deficiencies in most areas (including work, family relations, judgment, thinking, or mood) with symptoms such as suicidal ideation; depressed mood; anxiety; irritability; anger; suspiciousness; chronic sleep impairment; flattened affect; difficulty understanding complex commands; impairment of short- and long-term memory; impaired judgment; disturbances of motivation and mood; near continuous depression affected the ability to function independently, appropriately, and effectively; impaired impulse control; and difficulty in establishing and maintaining effective work and social relationships. 2. Throughout the entire period on appeal, the Veteran's acquired psychiatric disorder did not result in more severe manifestations that more nearly approximate total occupational and social impairment. 3. During the period on appeal prior to May 1, 2019, the Veteran's service-connected disabilities precluded him from securing and maintaining a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 70 percent, but no higher, for an acquired psychiatric disability, to include depressive disorder and PTSD, have been met for the period on appeal prior to May 1, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411, 9434. 2. The criteria for an evaluation in excess of 70 percent for an acquired psychiatric disability, to include depressive disorder and PTSD, have not been met for the period on appeal beginning May 1, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, DC 9411, 9434. 3. The criteria for entitlement to a TDIU have been met for the period on appeal prior to May 1, 2019. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1985 to March 1989 and from February 2003 to June 2004. The Veteran contends that he is entitled to increased ratings for an acquired psychiatric disorder, to include depressive disorder and post-traumatic stress disorder (PTSD). He also contends that he is entitled to a total disability rating based on unemployability due to service-connected disabilities (TDIU) for the period on appeal prior to May 1, 2019. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions from November 2014 and July 2020 by a Department of Veterans Affairs (VA) Regional Office (RO). The Board acknowledges that the Veteran submitted a Rapid Appeals Modernization Program (RAMP) opt-in election form that was received by VA on June 11, 2018. However, the appeal had already been activated at the Board and is therefore no longer eligible for the RAMP program. Accordingly, the Board will undertake appellate review of the case. I. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Entitlement to Increased Ratings for an Acquired Psychiatric Disorder. For the Veteran's service-connected acquired psychiatric disorder, to include depressive disorder and PTSD, he contends that he is entitled to an evaluation in excess of 30 percent for the period on appeal prior to May 1, 2019, and he contends that he is entitled to an evaluation in excess of 70 percent for the period beginning May 1, 2019. The Veteran first filed a claim of service connection for a psychiatric condition in April 2008. The RO initially denied service connection for post-traumatic stress disorder (PTSD), to include depression, in a December 2008 rating decision. The Veteran timely appealed this decision but later withdrew his appeal in January 2014. The Veteran filed a new claim of service connection for a psychiatric condition on January 16, 2014. In an April 2014 rating decision, the RO granted service connection for depressive disorder, not otherwise specified (NOS), with a 30 percent evaluation, effective January 16, 2014. The Veteran filed a claim for an increased rating for a psychiatric condition in August 2014. The claim was denied in a November 2014 rating decision. The Veteran timely appealed. In a November 2016 rating decision, the RO granted the Veteran service connection for PTSD, effective January 16, 2014. The PTSD was evaluated together with the depressive disorder to avoid pyramiding. Later in a July 2020 rating decision, the RO granted the Veteran an increased evaluation of 70 percent, effective May 1, 2019. The RO stated that this was the date that VA received an Intent to File from the Veteran. The Veteran's acquired psychiatric disorder depressive disorder was rated pursuant to DC 9411 and 9434, which provide that the disability is evaluated pursuant to the General Rating Formula for Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130. Under the General Rating Formula, a 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although functioning satisfactorily with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating contemplates 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; impairments of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. VazquezClaudio v. Shinseki, 713 F.3d 112, 11617 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130. Further, when evaluating a mental disorder, 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," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a). In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the general rating formula "indicates that the presence of suicidal ideation alone...may cause occupational and social impairment with deficiencies in most areas." However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment. Turning to the evidence of record, the Veteran has received social security administration (SSA) disability benefits since April 2008. In the related SSA Disability Determination, the primary diagnosis listed is affective disorder. In a February 2013 VA Psychiatry Consult, the Veteran reported feeling anxious and depressed. He experienced recurrent nightmares and flashbacks relating to his time in active service in Iraq where he saw people dying. He also reported excessive guilt regarding a serviceman who was taunted by others and then committed suicide. He stated that he saw shadows moving at times and heard noises like horns blowing. He denied hearing voices. He reported periods of excessive irritability and anger. He denied physical violence; but he stated that he was recently hit in the face during an argument, and he was partially responsible for this outcome. He denied suicidal ideas; but he had a history of suicidal gestures, the last of which was in 2009, and he reported chronic passive death wishes. He reported that he was hospitalized at Panamericano in 2005 due to a suicidal gesture with a gun. He also reported two hanging attempts in 2007 and 2009. The examiner observed that the Veteran appeared apprehensive and anxious. His speech had a normal rate and volume. His mood was dysphoric, and his affect was anxious and constricted. His thought processes were linear and goal-directed. There were no loose associations or flights of ideas. His insight into his illness was fair, and his social judgment was good. The examiner diagnosed the Veteran with severe recurrent major depression and PTSD. In a February 2013 private treatment discharge summary, the examiner diagnosed the Veteran with severe recurrent major depressive disorder (MDD) with psychotic features and PTSD. The Veteran had mood disorders, levels of anxiety that hindered effective functioning, alterations in sleep patterns, alterations in eating patterns, and financial problems. He also had insomnia, crying spells, irritability, inability to do daily tasks, poor social interaction, and nightmares. The Veteran presented with deterioration of cognitive functions, memory problems, and poor capacity for sustaining concentration and attention. The examiner observed that the Veteran's attitude and appearance was suspicious and unkempt. His speech, thought, and perception were slow with ideas of worthlessness, pessimism, frustration, and ideas or thoughts of death. He had poor attention, poor capacity to do simple calculations, poor judgment, and poor introvision. The Veteran did not go shopping, and he did not have hobbies. He did not take public transportation or drive. Regarding the Veteran's ability to function in a work setting, the examiner stated that the Veteran does not follow instructions, does not make decisions, and becomes depressed. The examiner opined that the Veteran could not sustain activity that generates income due to his clinical condition and diminished cognitive functions. In a March 2013 VA Psychiatry Telephone Encounter Note, the Veteran reported that, in the past, he had a gambling and drinking problem, which was now resolved. However, these problems had caused significant problems in his marriage, which now made him feel guilty and depressed. In a July 2013 VA Psychiatry Note, the examiner diagnosed the Veteran with severe recurrent depression. The examiner reported feeling significantly better since restarting his medications. He stated that he felt calmer and not depressed more often than not. He no longer had death wishes. In a November 2013 private treatment note, the Veteran reported feeling sad often. He had unexplained feelings of worthlessness, lack of motivation, discomfort and pains, and unexplained drowsiness; and he felt more irritable than normal. He did not spend as much time with friends and family as before. In a November 2013 private PTSD disability benefits questionnaire (DBQ) a private examiner diagnosed the Veteran with severe major depression and PTSD. The private examiner stated that the Veteran had dysuria and traumatic symptoms that have been treated since June 2006. The private examiner also stated that PTSD and major depression are comorbid, although depressive symptoms came after traumatic exposure. The private examiner stated that the Veteran's psychiatric condition caused total occupational and social impairment. The private examiner stated that, due to the Veteran's condition, his relationship with his wife had been affected in both intimacy and daily interactions. The Veteran startled easily; and he was sometimes very tense, apprehensive, and hostile. He was very suspicious toward others and socially withdrawn. He behaved violently without any provocation in his civilian life. The examiner stated that the Veteran had no known history of substance use disorder or alcohol dependence or abuse. The private examiner noted that the Veteran depended absolutely on constant psychotropic medications. The private examiner found that the Veteran had symptoms of depressed mood; anxiety; suspiciousness; near continuous panic or depression affecting ability to function independently, appropriately, or effectively; chronic sleep impairment; impairment of short and long term memory; difficulty understanding complex commands; impaired judgment; impaired abstract thinking; disturbances in motivation and mood; difficulty establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships; grossly inappropriate behavior; and intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). The private examiner stated that the Veteran was not capable of managing his financial affairs. His brother was his tutor, and his wife took care of other basic household needs and chores. The private examiner noted that he had treated the Veteran since 2006. He opined that the Veteran's case was a typical case of a delayed PTSD disorder, which was exacerbated and related to military exposure. At a March 2014 VA Psychology Note, the examiner diagnosed the Veteran with unspecified depressive disorder. The Veteran reported that he had some trouble at home. He would get angry, and everyone would get defensive. He described heightened anxiety and irritability that had led to verbal anger outbursts that had an impact on interpersonal relationships with family. The Veteran also reported a history of violent ideation. For example, in 2011, he thought about hitting a neighbor with a bat in a disagreement, but he had no intention of carrying out the physical assault. The Veteran was concerned about his intense anger and poor frustration tolerance. He denied physical assaults of objects or people. The Veteran reported that he had fluctuations in mood, poor frustration tolerance, hyper-vigilance, and nightmares; and he had become increasingly withdrawn. He endorsed a history of auditory hallucinations, including hearing his name called; but he denied current perceptual disturbances. He denied suicidal, homicidal, or violent ideas, plans, intents, or attempts. He reported a history of problematic alcohol consumption, which he stopped six years ago. The Veteran identified stressors of daily life present in social environment and daily interpersonal interactions that lead to exacerbation of symptoms. He expressed that anxiety and irritability impact his ability to interact with others, and he often isolated or withdrew from others to manage distress. At an April 2014 VA examination, the examiner diagnosed the Veteran with depressive disorder NOS. The examiner found that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under DSM-5 criteria. The examiner stated that the Veteran's psychiatric condition resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The VA examiner found that the Veteran had symptoms of depressed mood, anxiety, trouble sleeping, and irritability; and the Veteran was capable of managing his financial affairs. The Veteran reported that he had been married twice and divorced once. At the time of this examination, he had been separated from his second wife for two months, and he lived with his mother. He had three children. He had been accused twice of domestic violence. He described his social relationships as "few". He enjoyed taking care of pets, talking to his children, and listening to the radio. He had a high school education. He reported that he had one in-patient psychiatric hospitalization and one partial hospitalization. At an October 2014 VA Psychology Note, the Veteran reported constant anxiety, restlessness, desperation, and depression, which made him want to be socially isolated. This in turn fomented marital difficulties to the point of verbal violence and police intervention, as well as inability to manage stress, poor frustration tolerance, impulsivity, late onset insomnia, sadness, crying spells, and hypervigilance. The Veteran reported that his relationship with his wife was tense, and his relationship with his adolescent stepson was conflictive. He stated that he chose to remain distant from acquaintances and past friendships. At an April 2015 VA Psychiatry Note, the Veteran stated that he does not drive because he becomes agitated with other drivers on the street. His wife drives the family around. At an August 2015 VA Social Work Initial Evaluation Note, the Veteran reported that he drinks alcohol in excess and engages in gambling. Both of these had caused many problems, including monetary losses, marital problems, and difficulties with his children. He reported drinking, gambling, and losing money a week ago. His wife had given him an ultimatum and a few days to leave the house. The next day, the Veteran presented at the VA for an unscheduled appointment. He reported feeling depressed and out of control. He had problems with his wife and active ideas of suicide by hanging. Other VA medical records from August 2015 indicate that the Veteran was admitted to the psychiatric unit for inpatient care. He presented with symptoms of depression, anxiety, and PTSD and suicidal ideas. The Veteran reported that his depression had worsened in the last three or four months. He reported suicidal ideas for the past two months. At present, he had ideas of hanging himself, and he had written a suicide note while very anxious and depressed. He related this worsening of symptoms to recent worsening of his gambling behavior. He stated that he would gamble more than planned, lie to others in order to gamble, increase the amount of time and money spent in gambling, and gamble to chase lost money. The Veteran also reported chronic PTSD symptoms like flashbacks, nightmares, irritability, and survivor's guilt. He presented with depressive symptoms of sadness, anhedonia, crying spells, hopelessness, helplessness, worthlessness, excessive guilt, decreased appetite, insomnia, poor concentration, social isolation, and family and marital dysfunction. The Veteran was discharged a few days later, after which he continued outpatient treatment, including individual therapy, group therapy, and addition-related therapy. In a February 2016 VA Psychiatry Note, the Veteran reported that he was going to church weekly, and this had been helping. He had also returned to live with his wife and children, though they still resented him for losing $10,000.00 in gambling. He denied gambling or alcohol since his last visit. In a June 2016 VA Addiction Psychiatry Therapist Note, the Veteran reported that his triggers included lack of support or trust from his family; and he coped by avoiding people, places, and things. He stated his church was his major support now. At an October 2016 VA examination, the VA examiner diagnosed the Veteran with unspecified depressive disorder, and he found that the Veteran did not meet the diagnostic criteria for PTSD under DMS-V. The VA examiner stated that the Veteran's psychiatric condition resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The VA examiner found that the Veteran had symptoms of depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The Veteran also had alcohol use disorder with a history of alcohol dependence since 2000. He reported that he was hospitalized at Panamericano in 2005 on account of his alcohol dependence. He also enrolled in a VA addiction clinic in 2016. The Veteran also had pathological gambling in early partial remission. He stated that he had been gambling since a long time ago, and he kept this information from his treating psychiatrist to avoid disgregation of his PTSD claim. The examiner stated that the Veteran had more than one mental disorder diagnosed, but it was not possible to differentiate what symptoms were attributable to each diagnosis. The examiner noted that the Veteran had been drinking alcohol and gambling since before his 2003 deployment. The Veteran reported that his children from his first marriage were adults, and he had two minor children from his second marriage. He was also raising a stepson. At the time of this examination, the Veteran lived with his life, sons, and stepson. The Veteran reported that his wife accused him of domestic violence, and as a result, he was disarmed from his job as a correctional officer in 2006. The October 2016 VA examiner observed that the Veteran was well-developed and well-nourished, and he came to the interview appropriately dressed with adequate hygiene. The Veteran was cooperative and spontaneous, and he established eye contact with the examiner. He was alert and in contact with reality. There was no evidence of psychomotor retardation or agitation. There were no tics, tremors, or abnormal involuntary movement. The Veteran's thought process was coherent and logical. There was no looseness of association and no sign of disorganized speech. There were no sign of delusions and no sign of hallucinations. There were no phobias, obsession, panic attacks, or suicidal ideas. The Veteran's mood was anxious, and his affect was broad and appropriate. He was oriented in person, place, and time; and his memory for recent, remote, and immediate events was preserved. His abstraction capacity was normal. His judgment was good, and his insight was adequate. The Veteran was capable of managing his financial affairs. At an August 2017 VA Psychology Note, the Veteran reported that he quit alcohol and gambling, and he was having communication difficulties with his wife and son. He reported that he was having nightmares, flashbacks, and thoughts from active service. He stated that, when he is depressed, he gets very nervous and irritable, argues for anything, and says things he does not mean. He reported that he has had three suicide attempts; and he resigned from his job because he did not feel like going, and he became irresponsible with his duties. He stated that he goes to church and receives support from church members. The Veteran indicated that he gets violent and isolated and makes bad decisions. He does not want to hear advice, does not coordinate his thoughts well, and does not want to listen to anybody. He stated that he needs to be medicated to avoid "going crazy and losing it". He reported feeling guilty because one of his friends committed suicide while in combat. He indicated that he is constantly thinking how he could have avoided some of the events that happened in combat, how he could have done things differently, and how guilty he thinks he is. The Veteran endorsed PTSD symptoms such as re-experiencing, hypervigilance, avoidance, witnessing traumatic events. He denied having suicidal ideas, plans or intentions in the past year. The examiner diagnosed the Veteran with recurrent MDD and moderate chronic PTSD. At a February 2018 VA Psychiatry appointment, the Veteran presented with symptoms of memory loss, poor concentration, decreased problem solving capacity, anxiety, restlessness, muscular tension, and nervousness. At a February 2018 VA examination, the VA examiner diagnosed the Veteran with moderate recurrent MDD and PTSD. The examiner stated that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication. The examiner noted that the Veteran had more than one mental disorder diagnosed, but it was not possible to differentiate what symptoms were attributable to each diagnosis. The examiner also noted that about 50 percent of veterans with PTSD also have a comorbid depressive disorder, and they can have overlapping symptoms. The VA examiner found that the Veteran had symptoms of depressed mood, anxiety, chronic sleep impairment, flattened affect, and disturbances in motivation and mood. The VA examiner observed that the Veteran was alert, coherent, relevant, logical, appropriate, and oriented. He was not suicidal or homicidal. His judgment and insight were poor. His mood was depressed, and his affect was congruent with his mood. There were no indications of a perceptual or thought disorder, and he seemed in good contact with reality. The Veteran was capable of managing his financial affairs. The Veteran reported that he had two adult children and six grandchildren. He also had two children from his second wife with whom he lived. He stated that his family relationships had problems, but they were still together. The Veteran reported that he had psychiatric treatment at the VA, and he was last seen in March 2017. The Veteran had a history of alcohol use disorder, but he claimed abstinence for about eight months. He also smoked a pack of cigarettes a day. At a May 2019 VA Psychology Note, the Veteran reported that he recently found out his wife was having an affair with a friend. He stated that he was not able to sleep because his mind was constantly telling him to check on his wife. He indicated that he and his wife argue every day, and he is indecisive of whether he should get a divorce. He stated that he stays mainly because of the children, but the situation in the house is very tense. He stated that he has forgotten appointments and avoided coming to the clinic because he was ashamed to share this information. In a May 2019 VA Psychiatry Note from a couple weeks later, the Veteran reported having uncontrolled anxiety, ruminating thoughts difficulty sleeping, and marital conflicts. He admitted to drinking beer on the weekends. He also presented with sadness, irritability, insomnia, poor concentration, decreased problem solving capacity, family and marital dysfunction, anxiety, restlessness, muscular tension, and nervousness. At a June 2020 VA examination, the VA examiner diagnosed the Veteran with PTSD; and the examiner stated that the Veteran's psychiatric condition resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The VA examiner found that the Veteran exhibited symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control. The Veteran presented as tense, attentive, and communicative; and he looked unhappy. He exhibited speech with a normal rate, volume, and articulation; and he was coherent and spontaneous. His language skills were intact. His mood was normal with no signs of depression or mood elevation. His affect was appropriate, full range, and congruent with his mood. Associations were intact and logical. There was no apparent sign of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. His thinking was logical, and his thought content appeared appropriate. He denied suicidal ideas or intentions; and no homicidal ideas or intentions were reported. The Veteran was capable of managing his financial affairs. The VA examiner noted that features of depression were part of the Veteran's PTSD diagnosis. The Veteran reported that he lived with his wife and 17-year-old son. The Veteran stated that he sometimes goes to church. He reported that he argues frequently with his wife and son, and he can get aggressive. He was also sometimes sad. He liked to be alone and stay in his room. He stated that, when he is anxious, he explodes for anything. Then when he realizes what he did, it is too late, and he feels guilty. The Veteran reported that, about a year ago, he had a situation with his neighbor. His neighbor called the cops and filed a complaint, but it was archived. On two occasions, the neighbors called the cops because he was arguing with his wife, but since his wife did not follow up with the complaint, nothing happened. The Veteran reported that it had been a year and one and a half years since he had substances or alcohol. The Board has additionally reviewed the balance of the Veteran's other medical treatment records from the period on appeal. The findings in the other medical treatment records are substantially similar to those noted in the examinations and treatment records described above. After review of the record as described above, it appears that, during the entire period on appeal, the Veteran's symptoms associated with his acquired psychiatric disability, to include depressive disorder and PTSD, have more closely paralleled the types of symptoms in the criteria for a 70 percent disability rating. Throughout the appeal period, the Veteran exhibited occupational and social impairment with deficiencies in most areas (including work, family relations, judgment, thinking, or mood) with symptoms including but not limited to suicidal ideation, depressed mood; anxiety; irritability; anger; suspiciousness; chronic sleep impairment; difficulty understanding complex commands; impairment of short- and long-term memory; impaired judgment; disturbances of motivation and mood; near continuous depression affected the ability to function independently, appropriately, and effectively; impaired impulse control; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9413. Therefore, the Board finds that an evaluation of 70 percent, but no higher, is warranted for the Veteran's acquired psychiatric disorder, to include depressive disorder and PTSD, for the entire period on appeal, including the period prior to May 1, 2019. A higher rating of 100 percent is not warranted at any point during the period on appeal, as the Veteran's depressive disorder has not resulted in total occupational and social impairment, and he did not have symptoms or overall impairment more closely approximating the criteria for a 100 percent disability rating. 38 C.F.R. § 4.130, DC 9413. In this regard, the Veteran has not exhibited symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Id. Thus, an evaluation in excess of 70 percent for an acquired psychiatric disorder, to include depressive disorder and PTSD, is not warranted in this case. The Board acknowledges the Veteran's assertions that his psychiatric disorder was of a sufficient severity so as to warrant higher disability ratings in excess of 70 percent. However, the competent medical evidence offering specific determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. Thus, the Veteran's own assessment as to the severity of the symptoms and their relationship to the rating criteria are less probative than the opinions of medical practitioners who have specialized knowledge and skill in excess of him. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert, supra. In reaching the foregoing conclusion, the Board has resolved all doubt in the Veteran's favor, which has resulted in an increased rating of 70 percent for the Veteran's acquired psychiatric disorder, to include depressive disorder and PTSD, for the period on appeal prior to May 1, 2019. However, to the extent that a higher rating is denied herein, the Board finds that the preponderance of the evidence is against such aspect of the Veteran's claim. Consequently, the benefit of the doubt doctrine is not applicable in such regard, and the Veteran's claim for a higher rating is otherwise denied. 38 U.S.C. 5107; 38 C.F.R. 4.3, 4.7. II. Entitlement to a Total Disability Evaluation Based on Individual Unemployability (TDIU) The Veteran contends that he is entitled to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) for the period on appeal prior to May 1, 2019. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is 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, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). A claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) may be raised as a separate claim, or it may be raised in the context of an initial rating or a claim for an increase. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran's master's degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In Ray v. Wilkie, 31 Vet. App. 58 (2019), the United States Court of Appeals for Veterans Claims (Court) held that the initial extra-schedular referral decision under § 4.16(b) should address whether there is "sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities". Moreover, the Court defined the term "unable to secure and follow a substantially gainful occupation" in § 4.16(b) to include two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. In this case, the Veteran's claim for a TDIU arose during the pending of his current appeal for increased ratings an acquired psychiatric disorder, to include depressive disorder and post-traumatic stress disorder (PTSD). That appeal can be traced back to a claim filed on January 16, 2014. Thus, the current period on appeal for the issue of entitlement to a TDIU begins on January 16, 2014. In a July 1, 2020 rating decision, the RO granted the Veteran entitlement to a TDIU for the period on appeal beginning May 1, 2019. The RO stated that this was the date that VA received an Intent to File from the Veteran. Service connection has been established for an acquired psychiatric disorder (to include depressive disorder and PTSD), lumbar muscle spasm, and tinnitus. For the period on appeal, the Veteran's acquired psychiatric disorder is rated at 70 percent disabling, as discussed in the previous section. The Board will add this to the Veteran's combined evaluations. The Veteran's lumbar muscle spasm is rated at 20 percent disabling from July 4, 2017 to May 1, 2019; and it is rated at 40 percent disabling for the period on appeal beginning May 1, 2019. The Veteran's tinnitus is rated as 10 percent disabling for the period beginning January 3, 2018. For the period on appeal prior to July 4, 2017, the Veteran has a combined disability evaluation of 70 percent. For the period on appeal beginning July 4, 2017, the Veteran's combined disability evaluation is 80 percent. Thus, the Veteran does meet the schedular threshold for consideration of a TDIU during the period on appeal. The question in this case is whether the Veteran's service-connected disabilities have precluded him from participating in substantially gainful employment during the period on appeal. The Veteran first submitted a VA Form 21-8940 Veteran's Application for Increased Compensation Based on Unemployability (TDIU Application) on January 22, 2018. In the TDIU Application, the Veteran stated that his major depressive disorder (MDD), PTSD, back condition, hearing loss, and tinnitus prevented him from securing or following any substantially gainful occupation. He reported that his disability affected his full-time employment on June 14, 2004. He last worked full time on February 12, 2005, and he became too disabled to work on that date. The most he had ever earned in a year was $20,400.00 in 2002 when he worked as a correctional officer. His employer was the Commonwealth of Puerto Rico, for which he worked as a correctional officer from January 1, 1998 to February 12, 2005. He stated that he left his last job because of his disability. He has not tried to obtain employment since he became too disabled to work. He reported that he completed his high school education. He did not have any other education or training before or since becoming too disabled to work. The Veteran noted that he was laid off from his job due to his service-connected condition. In a VA Form 21-4192 Request for Employment Information, the Veteran's employer at a correctional institute in Puerto Rico, reported that the Veteran worked for them as a correctional officer from June 4, 1991 to February 12, 2005. The Veteran earned $20,400.00 in the 12 months preceding the last date of employment, and he lost 30 days of work in the 12 months preceding the last date of employment. The Veteran's last payment on February 12, 2005 had a gross amount of $1,700.00. The Veteran's employer stated that the reason for termination of employment was his MDD. The employer stated that, due to his mental condition of PTSD and MDD, he could not continue doing his job as a correctional custody officer. The Veteran submitted an updated TDIU Application on March 5, 2020. In the updated TDIU Application, the Veteran stated that his MDD, PTSD, back injury, and tinnitus prevented him from securing or following any substantially gainful occupation. He reported that his disability affected full-time employment on April 17, 2008. He last worked full time on January 20, 2005, and he became too disabled to work on October 12, 2004. He reported that he completed his high school education, and he did not have any other education or training before or since becoming too disabled to work. The Veteran stated that he has strong back pain that is getting stronger, and his mental condition affects him. He noted that he has social security disability, effective April 17, 2008. The record reflects that the Veteran has received social security administration (SSA) disability benefits since April 2008. In the related SSA Disability Determination, the primary diagnosis listed is affective disorder. In the Veteran's application for Social Security Administration (SSA) disability benefits, the Veteran reported that he worked full-time as a correctional officer at a prison from 1991 to January 2005. In that position, he earned $1,800.00 a month. In a November 2008 VA examination for the Veteran's spine, the Veteran reported that he had worked as a correction officer, but he was currently retired. He stated that the cause of his retirement included medical physical and psychiatric problems, such as chronic low back pain and major depression. At an April 2014 VA examination for his psychiatric disorder, the Veteran reported that he had a high school education. During active service, he was a motor vehicle mechanic, and he had combat experience in Iraq as a military policeman. He reported that, after active service, he worked for 16 years as a correctional officer, and he resigned in 2004. The Board notes that, although the Veteran has stated that his hearing loss impacted his ability to secure or follow any substantially gainful occupation, he is not currently service connected for hearing loss. As mentioned earlier, the Board cannot consider non-service-connected disabilities in a TDIU claim. Regarding the Veteran's service-connected acquired psychiatric disorder, in a February 2013 VA Psychiatry Consult, the Veteran reported feeling anxious and depressed. He reported periods of excessive irritability and anger. He denied physical violence; but he stated that he was recently hit in the face during an argument, and he was partially responsible for this outcome. The examiner observed that the Veteran appeared apprehensive and anxious. His speech had a normal rate and volume. His mood was dysphoric, and his affect was anxious and constricted. His thought processes were linear and goal-directed. There were no loose associations or flights of ideas. In a February 2013 private treatment discharge summary, the examiner diagnosed the Veteran with severe recurrent MDD with psychotic features and PTSD. The Veteran had mood disorders, levels of anxiety that hindered effective functioning, alterations in sleep patterns, alterations in eating patterns, and financial problems. He also had insomnia, crying spells, irritability, inability to do daily tasks, poor social interaction, and nightmares. The Veteran presented with deterioration of cognitive functions, memory problems, and poor capacity for sustaining concentration and attention. The examiner observed that the Veteran's attitude and appearance were suspicious and unkempt. His speech, thought, and perception were slow with ideas of worthlessness, pessimism, frustration, and ideas or thoughts of death. He had poor attention, poor capacity to do simple calculations, poor judgment, and poor introvision. The Veteran did not go shopping, and he did not have hobbies. He did not take public transportation or drive. Regarding the Veteran's ability to function in a work setting, the examiner stated that the Veteran does not follow instructions, does not make decisions, and becomes depressed. The examiner opined that the Veteran could not sustain activity that generates income due to his clinical condition and the diminished cognitive functions. In a November 2013 private treatment note, the Veteran reported feeling sad often. He had unexplained feelings of worthlessness, lack of motivation, discomfort and pains, unexplained drowsiness, and feeling more irritable than normal. He did not spend as much time with friends and family as before. In a November 2013 private PTSD disability benefits questionnaire (DBQ) a private examiner stated that the Veteran had dysuria and traumatic symptoms that have been treated since June 2006. The private examiner stated that, due to the Veteran's condition, his relationship with his wife had been affected in both intimacy and daily interactions. The Veteran startled easily; and he gets very tense, apprehensive, and hostile. He was very suspicious toward others and socially withdrawn. He behaved violently without any provocation in his civilian life. The private examiner found that the Veteran had symptoms of depressed mood; anxiety; suspiciousness; near continuous panic or depression affecting the ability to function independently, appropriately, or effectively; chronic sleep impairment; impairment of short and long term memory; difficulty understanding complex commands; impaired judgment; impaired abstract thinking; disturbances in motivation and mood; difficulty establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships; grossly inappropriate behavior; and intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). The private examiner stated that the Veteran was not capable of managing his financial affairs. His brother was his tutor, and his wife took care of other basic household needs and chores. At a March 2014 VA Psychology Note, the Veteran reported that he had some trouble at home. He would get angry, and everyone would get defensive. He described heightened anxiety and irritability that had led to verbal anger outbursts that had an impact on interpersonal relationships with family. The Veteran was concerned about his intense anger and poor frustration tolerance. The Veteran reported that he had fluctuations in mood, poor frustration tolerance, hyper-vigilance, and nightmares; and he had become increasingly withdrawn. The Veteran identified stressors of daily life present in his social environment and daily interpersonal interactions that lead to exacerbation of symptoms. He expressed that anxiety and irritability impact his ability to interact with others, and he often isolated or withdrew from others to manage distress. At an April 2014 VA examination, the VA examiner diagnosed the Veteran with depressive disorder, not otherwise specified (NOS), and found that the Veteran had symptoms of depressed mood, anxiety, trouble sleeping, and irritability. The Veteran was capable of managing his financial affairs. The Veteran reported that he had been accused twice of domestic violence. He described his social relationships as "few". He enjoyed taking care of pets, talking to his children, and listening to the radio. At an October 2014 VA Psychology Note, the Veteran reported constant anxiety, restlessness, desperation, and depression which made him want to be socially isolated. This in turn fomented his marital difficulties to the point of verbal violence and police intervention, as well as inability to manage stress, poor frustration tolerance, impulsivity, late onset insomnia, sadness, crying spells, and hypervigilance. The Veteran reported that his relationship with his wife was tense, and his relationship with his adolescent stepson was conflictive. He stated that he chose to remain distant from acquaintances and past friendships. At an April 2015 VA Psychiatry Note, the Veteran stated that he does not drive because he becomes agitated with other drivers on the street. His wife drives the family around. At an August 2015 VA Social Work Initial Evaluation Note, the Veteran reported that he drinks alcohol in excess and engages in gambling. Both of these had caused many problems, including monetary losses, marital problems, and difficulties with his children. He reported drinking, gambling, and losing money a week ago. His wife had given him an ultimatum and a few days to leave the house. The next day, the Veteran presented at the VA for an unscheduled appointment. He reported feeling depressed and out of control. He had problems with his wife and active ideas of suicide by hanging. Other VA medical records from August 2015 indicate that the Veteran was admitted to the psychiatric unit for inpatient care. He presented with symptoms of depression, anxiety, and PTSD and suicidal ideas. He reported suicidal ideas for the past two months. He had ideas of hanging himself, and he had written a suicide note while very anxious and depressed. He related this worsening of symptoms to recent worsening of his gambling behavior. He stated that he would gamble more than planned, lie to others in order to gamble, increase the amount of time and money spent in gambling, and gamble to chase lost money. The Veteran also reported chronic PTSD symptoms like flashbacks, nightmares, irritability, and survivor's guilt. He presented with depressive symptoms of sadness, anhedonia, crying spells, hopelessness, helplessness, worthlessness, excessive guilt, decreased appetite, insomnia, poor concentration, social isolation, and family and marital dysfunction. The Veteran was discharged a few days later, after which he continued outpatient treatment, including individual therapy, group therapy, and addition-related therapy. In a December 2015 Function Report related to his SSA disability benefits, the Veteran reported that he has concentration problems, and he is an anxious person. He stated that he has problems getting along with others, and he does not spend time with other people. He noted that he has suicidal thoughts. In a June 2016 VA Addiction Psychiatry Therapist Note, the Veteran reported that his triggers included lack of support or trust from his family; and he coped by avoiding people, places, and things. He stated his church was his major support now. At an October 2016 VA examination, the VA examiner diagnosed the Veteran with unspecified depressive disorder and found that the Veteran had symptoms of depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The Veteran also had alcohol use disorder with a history of alcohol dependence since 2000, and he had pathological gambling in early partial remission. The Veteran reported that his wife accused him of domestic violence, and as a result, he was disarmed from his job as a correctional officer in 2006. The VA examiner observed that the Veteran was well-developed and well-nourished, and he came to the interview appropriately dressed with adequate hygiene. The Veteran was cooperative and spontaneous, and he established eye contact with the examiner. He was alert and in contact with reality. There was no evidence of psychomotor retardation or agitation. There were no tics, tremors, or abnormal involuntary movement. The Veteran's thought process was coherent and logical. There was no looseness of association and no sign of disorganized speech. There were no sign of delusions and no sign of hallucinations. There were no phobias, obsession, panic attacks, or suicidal ideas. The Veteran's mood was anxious, and his affect was broad and appropriate. He was oriented in person, place, and time; and his memory for recent, remote, and immediate events was preserved. His abstraction capacity was normal. His judgment was good, and his insight was adequate. The Veteran was capable of managing his financial affairs. At an August 2017 VA Psychology Note, the Veteran reported that he was having communication difficulties with his wife and son. He reported having nightmares, flashbacks, and thoughts from active service. He stated that, when he is depressed, he gets very nervous and irritable, argues for anything, and says things he does not mean. He reported that he has had three suicide attempts; and he resigned from his job because he did not feel like going, and he became irresponsible with his duties. He stated that he goes to church and receives support from church members. The Veteran indicated that he gets violent and isolated and makes bad decisions. He stated that he needs to be medicated to avoid "going crazy and losing it". The Veteran endorsed PTSD symptoms such as re-experiencing, hypervigilance, avoidance, witnessing traumatic events. He denied having suicidal ideas, plans or intentions in the past year. The examiner diagnosed the Veteran with recurrent MDD and moderate chronic PTSD. At a February 2018 VA Psychiatry Note, the Veteran presented with symptoms of memory loss, poor concentration, decreased problem solving capacity, anxiety, restlessness, muscular tension, and nervousness. At a February 2018 VA examination, the VA examiner diagnosed the Veteran with moderate recurrent MDD and PTSD and found that the Veteran had symptoms of depressed mood, anxiety, chronic sleep impairment, flattened affect, and disturbances in motivation and mood. The VA examiner observed that the Veteran was alert, coherent, relevant, logical, appropriate, and oriented. His judgment and insight were poor. His mood was depressed, and his affect was congruent with his mood. The Veteran was capable of managing his financial affairs. The Veteran reported that his family relationships had problems, but they were still together. The VA examiner opined that the Veteran's psychiatric symptoms were not so severe as to preclude him from obtaining and maintaining gainful employment. At a May 2019 VA Psychology Note, the Veteran reported that he recently found out his wife was having an affair with a friend. He stated that he was not able to sleep because his mind was constantly telling him to check on his wife. The Veteran reported that he and his wife argue every day, and he is indecisive of whether he should get a divorce. He stated that he stays mainly because of the children, but the situation in the house is very tense. He stated that he has forgotten appointments and avoided coming to the clinic because he was ashamed to share this information. In a May 2019 VA Psychiatry Note from a couple weeks later, the Veteran reported having uncontrolled anxiety, ruminating thoughts difficulty sleeping, and marital conflicts. He admitted to drinking beer on the weekends. He also presented with sadness, irritability, insomnia, poor concentration, decreased problem solving capacity, family and marital dysfunction, anxiety, restlessness, muscular tension, and nervousness. Regarding the Veteran's service-connected lumbar muscle spasm, in a December 2015 Function Report related to his SSA disability benefits, the Veteran reported that he has back problems, and he cannot lift heavy things because of his back. In a February 2018 VA Physical Medicine Rehab Consult, the Veteran reported a history of back pain. A private MRI had shown degenerative disc disease (DDD) and mild cana stenosis with L5-S1 left foramina involvement and diffuse numbness in his left leg. The Veteran reported that he injured his back during active service in 2003, and since then, he has had back discomfort that has increased over time. His back discomfort limits activity. He cannot exercise and has difficulty getting up, and he has pain when bending forward. He cannot wash his car. He also cannot sleep because of back discomfort, and he has to turn frequently. He stated that the back pain is constant, and he has become sedentary. This has caused depression due to inactivity. He has been treated with oral medication. At an April 2018 VA examination, the VA examiner diagnosed the Veteran with lumbar muscle spasm. The Veteran complained of constant low back pain, which he described as having a pressure or stabbing-like pain sensation. The Veteran reported functional loss or functional impairment of the thoracolumbar spine (back) with limitation bending forward, standing, and sitting. The examiner found that the Veteran had forward flexion range of motion (ROM) of 40 degrees, extension ROM of 5 degrees, right and left lateral flexion ROM of 10 degrees, and right and left lateral rotation ROM of 15 degrees. The ROM itself did not contribute to a functional loss. Pain was noted on examination but did not result in or cause functional loss. Flexion, extension, right and left lateral flexion, and right and left lateral rotation exhibited pain. There was no evidence of pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the back with tenderness over lumbar paravertebral muscle. The Veteran was able to perform repetitive use testing with at least three repetitions, and there was no additional loss of function or ROM after three repetitions. The Veteran reported flare-ups of the thoracolumbar spine (back) with limitation in bending forward, standing, sitting, and dressing or undressing lower parts of the body. The examiner stated that pain could significantly limit functional ability during flare-ups or when the joint is used repeatedly over a period of time; but at the time of examination, there was no evidence of fatigability, incoordination, muscle weakness, or pain. There was evidence of pain with passive ROM, but there was no evidence of pain when the joint was used in non-weight bearing. The Veteran had guarding and muscle spasm of the thoracolumbar spine, but these did not result in an abnormal gait or abnormal spinal contour. The Veteran's muscle strength was normal. Reflex and sensory examinations were normal. A straight leg raising test was negative bilaterally. There was no muscle atrophy, radiculopathy, ankylosis, or intervertebral disc syndrome (IVDS). The Veteran occasionally used a brace and regularly used a cane due to low back pain. The examiner stated that the Veteran's back condition impacted his ability to work, and he should avoid lifting or carrying objects of more than 20lbs. At a March 2020 VA examination, the Veteran reported functional loss or functional impairment of the thoracolumbar spine (back) with limitation bending forward, standing, sitting and dressing and undressing lower parts of the body. The examiner found that the Veteran had forward flexion ROM of 30 degrees, extension ROM of 5 degrees, right and left lateral flexion ROM of 5 degrees, and right and left lateral rotation ROM of 5 degrees. Pain was noted on examination, and it caused functional loss. Flexion, extension, right and left lateral flexion, and right and left lateral rotation exhibited pain. There was no evidence of pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the back with tenderness over lumbar paravertebral muscle. The Veteran was able to perform repetitive use testing with at least three repetitions, and there was no additional loss of function or ROM after three repetitions. The Veteran was being examined immediately after repeated use over time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. The Veteran reported flare-ups of the thoracolumbar spine (back) with limitation in bending forward, standing, sitting, and dressing or undressing lower parts of the body. The examiner found that the examination was medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups. Pain caused this functional loss. In terms of ROM, during flare-ups, the Veteran had forward flexion ROM of 10 degrees, extension ROM of 0 degrees, right and left lateral flexion ROM of 5 degrees, and right and left lateral rotation ROM of 10 degrees. There was evidence of pain with passive ROM, but there was no evidence of pain when the joint was used in non-weight bearing. The Veteran's muscle strength was normal. Reflexes were rated at 1+ hypoactive. A sensory examination was normal, and a straight leg raising test was negative bilaterally. There was no muscle atrophy, radiculopathy, ankylosis, or IVDS. The Veteran occasionally used a brace and cane due to multiple joint pain. The VA examiner stated that the Veteran's back condition impacted his ability to work, and he should avoid lifting or carrying objects of more than 20lbs. Regarding the Veteran's service-connected tinnitus, at a February 2018 VA examination, the Veteran reported recurrent tinnitus since he was exposed to multiple aircraft noise during active service. The VA examiner stated that the Veteran's tinnitus did not impact ordinary conditions of daily life, including the ability to work. The Board has additionally reviewed the balance of the Veteran's other medical treatment records from the period on appeal. The findings in the other medical treatment records are substantially similar to those noted in the medical examinations and treatment records described above. Based on the evidence as described above, the Board finds that, for the period on appeal, the evidence is in equipoise regarding whether the Veteran's service-connected disabilities, including his acquired psychiatric disability, back disorder, and tinnitus, precluded him from securing or following substantially gainful employment during the period on appeal prior to May 1, 2019. Considering the Veteran's psychiatric and physical limitations, the Veteran's education and background are not such that indicates that he would be able to secure and follow a substantially gainful occupation under the facts of this case. Therefore, resolving reasonable doubt in the Veteran's favor, the Board finds that entitlement to a TDIU is warranted for the entire period on appeal, including the period prior to May 1, 2019. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Tracie N. Wesner Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dawn A. Leung, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.