Citation Nr: 21073197 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 15-13 421 DATE: December 7, 2021 ORDER Entitlement to service connection for hypertension as secondary to posttraumatic stress disorder (PTSD) with alcohol use disorder is dismissed. Entitlement to an initial rating of 70 percent for the appeal period prior to August 27, 2020 for PTSD with alcohol use disorder is granted. Entitlement to a rating in excess of 70 percent for the appeal period beginning on August 27, 2020 for service-connected PTSD with alcohol use disorder is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. In a June 2021 statement, the Veteran, through his attorney, withdrew the claim of entitlement to service connection for hypertension. 2. The Veteran declined to be scheduled for a VA examination in June 2021. 3. Throughout the period on appeal, the Veteran's service-connected PTSD with alcohol use disorder manifested as occupational and social impairment with deficiencies in most areas without total social and occupational impairment. 4. The Veteran's service-connected disabilities prevented him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria are met for a withdrawal of the Veteran's appeal for the claim of entitlement for service connection for hypertension. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 2. The criteria for an initial rating of 70 percent for the appeal period prior to August 27, 2020 for PTSD with alcohol use disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for a rating in excess of 70 percent for the appeal period beginning on August 27, 2020 for PTSD with alcohol use disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.655, 4.14.14, 4.126, 4.130, Diagnostic Code 9411. 4. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1979 to October 1979, and from October 1986 to July 1987. These matters come to the Board of Veterans' Appeals (Board) on appeal from a February 2014 and April 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The issues with the exception of the TDIU claim was last remanded in an April 2020. The Board directed the RO to obtain and associate the claims file with the Veteran's vocational rehabilitation program records and an addendum VA opinion to determine the etiology of the Veteran's acquired mental health disorder other than PTSD. Upon remand, vocational rehabilitation program documents and updated VA treatment records were associated with the record. The RO attempted to schedule a VA examination to determine the current severity of the Veteran's PTSD in June 2021; however, the Veteran declined the examination citing advice from his attorney. The Board therefore determines that there has been substantial compliance with its previous remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). A September 2020 rating decision granted the Veteran's claim for service connection for alcohol use disorder. As this decision represents a full grant of the benefits sought with respect to this claim for service connection, such issue is no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). In a September 2020 rating decision, the agency of original jurisdiction (AOJ) granted a 50 percent rating for the appeal period prior to August 27, 2020 and 70 percent thereafter for PTSD with alcohol use disorder. However, a higher rating is available for PTSD with alcohol use disorder. The Veteran is presumed to seek the maximum available benefit for a disability. As such, this claim is still considered to be on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). DISMISSAL 1. Entitlement to service connection for hypertension as secondary to PTSD with alcohol use disorder is dismissed. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 19.55. By letter dated in June 2021, the Veteran, through his representative, submitted a statement stating that the Veteran wished to withdraw his claim of entitlement to service connection for hypertension. This statement was signed and submitted by the Veteran's attorney. The withdrawal was effective immediately upon receipt by VA. 38 C.F.R. § 19.55(b)(3). The Board finds that the Veteran's withdrawal is unambiguous, was in writing, included the name of the veteran, the file number and a statement that the appeal is withdrawn. See Hembree v. Wilkie, 33 Vet. App. 1 (2020). Thus, as there remains no allegation of error of fact or law for appellate consideration, the Board does not have jurisdiction to review the appeal as to the above-mentioned issue, and it is dismissed. The attorney's request presumes that the Board will find that the Veteran would be granted a total rating for PTSD with alcohol use disorder from December 27, 2011 onward. His optimistic belief regarding that claim does not create an ambiguity as to whether he is now withdrawing the other claim. There is no indication that there is any confusion on anyone's part as to whether this claim will still be pending after receipt of the withdrawal statement. The attorney did not present argument regarding these other claims, nor did he ask that the withdrawal be ignored if the total rating claim is denied. As the statement clearly sets forth the issues to be withdrawn with an understanding of the consequences of the action, the claim is dismissed. INCREASED RATING 2. Entitlement to an initial rating of 70 percent for the appeal period prior to August 27, 2020 for PTSD with alcohol use disorder is granted. 3. Entitlement to a rating in excess of 70 percent for the appeal period beginning on August 27, 2020 for PTSD with alcohol use disorder is denied. The Veteran and his attorney assert that the Veteran's PTSD warrants a higher rating. Specifically, in the June 2021 correspondence, the Veteran's attorney asserted that the Veteran's PTSD warranted either an assignment of total 100 percent rating for his PTSD or 70 percent rating with a grant of TDIU. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 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. Psychiatric disabilities are rated based on the General Rating Formula for Mental Disorders codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, a 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material; forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. The criteria for a 100 percent rating are 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 hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all 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. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the United States Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board after August 2014. As such, the DSM-5 applies, and the GAF scores will not be considered. As previously noted, the RO attempted to schedule a VA examination to determine the current severity of the Veteran's PTSD in June 2021; however, the Veteran declined the examination citing advice from his attorney In such cases, 38 C.F.R. § 3.655(a) provides that, when entitlement to a benefit cannot be established without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination or reexamination, action shall be taken in accordance with 38 C.F.R. § 3.655(b) or (c) as appropriate. Under 38 C.F.R. § 3.655(b), when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with, as relevant, a claim for increase, the claim shall be denied. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant or the death of an immediate family member. 38 C.F.R. § 3.655(a). As the instant claim stems from an initial rating, it will be rated based upon the evidence of record. A review of the record reveals that the Veteran has sought mental health treatment from VA and private facilities, as well as treatment for his other health needs. To the extent that the Veteran's treatment records contain information relevant to the severity of his mental health, to include mental health screenings, the Board will summarize this evidence. Turning to the evidence of record, the Veteran reported for an initial PTSD VA examination in December 2013. The Veteran was diagnosed with PTSD, bipolar disorder I, alcohol use disorder, and cannabis use disorder. The examiner found that it is possible to differentiate what symptom(s) are attributable to which diagnosis; for PTSD, reexperiencing, avoiding and sensitivity to triggers, and negative cognitions associated with the trauma were attributable. For alcohol use disorder and cannabis use disorder, the use of substance in spite of problems caused by their use was attributed. The examiner reported that occupational and social impairment level was 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 did not assign an occupational and social impairment level for any other mental health conditions during this examination. The Veteran reported relevant social/marital/family history to having difficulty maintaining a long-term relationship and not having kept in contact with his children. He reported that he does not belong to any clubs or organizations or have any recreational or leisure activities and that he has few friends. Regarding his occupational and educational history, the Veteran reported to doing well in school but leaving to join the service at 17. He completed two years of college, majoring in art, but did not complete the degree due to excessive alcohol use and deciding not to complete the degree. He reported to having "over 100 jobs," most of them having to do with jobs that required driving a taxi or a truck. He reported to having interpersonal problems with coworkers or supervisors, due to him becoming easily irritated or frustrated, which eventually led to him leaving the job. The examiner observed depression, anxiety, insomnia, and alcohol and substance abuse as presenting symptoms. For VA rating purposes, the Veteran was observed with anxiety, suspiciousness, and panic attacks that occur weekly or less often. At the examination, the Veteran appeared to be neatly groomed, appropriately dressed, restless in psychomotor activity/mannerisms/behaviors, but alert and fully oriented. He had spontaneous, coherent, and goal directed speech, with cooperative attitude toward the examiner. The affect was appropriate although the mood was reported as getting easily irritated with people, having a panic attack two years prior due to a driving unde the influence. He did report to past episodes of depression but no diminished interest or pleasure. He did report to some weight gain with limited sleep of four hours, categorized as initial and middle insomnia. The Veteran also denied thought of harm to self or others for the past three years, although he did have two prior attempts in the 1980's. He denied libido, sexual concerns, and crying spells. He did not exhibit obsessive or ritualistic behavior, although he did report to being easily distracted when studying and was able to recall remote and recent events during the interview. He reported no hallucinations, delusions or signs of thought disorder. The examiner then confirmed that the Veteran did not have any other symptoms attributable to PTSD and other mental disorders not already listed. The examiner also confirmed that the DSM-5 was used. The Veteran reported for a March 2015 PTSD VA examination, where the Veteran was diagnosed with PTSD, bipolar I disorder with mixed features, and alcohol use disorder with cannabis use. The examiner attributed to PTSD the following symptoms: reexperiencing, sensitivity to and avoidance of reminders, estrangement, hypervigilance, and sleep disturbance. The examiner attributed irritability, racing thoughts, pressured speech, and decreased need for sleep to the bipolar disorder. Lastly, the examiner attributed excessive, compulsive, and continued use in the face of consequences, loss of control, preoccupation, and craving to alcohol and cannabis use. Regarding occupational and social impairment level, the examiner reported 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 best summarized the Veteran's level. At the time of the interview, the Veteran had reported to living alone, having no driver's license, and only one female friend over the phone, with otherwise, no social life. He also reported that he did not have contact with relatives. Regarding employment, the Veteran mostly worked with driving trucks, deliveries, with a lot of job changes. The Veteran was a full-time student but left in the May of 2014 and not working or in school since then. He usually spent his time at home watching television. The Veteran did have a history of substance-related charges although at the time of the examination, the Veteran had no legal issues. The Veteran also reported to substance abuse and binge drinking for many years. The examiner observed the following symptoms for VA rating purposes: depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, and chronic sleep impairment. Behavioral observations showed pressured speech, no indication of psychotic process, gross cognitive impairment, obsessions or compulsions. The Veteran then reported for a VA examination in August 2020. The examiner confirmed PTSD and moderate alcohol use disorder. The examiner denied that the Veteran had more than one mental disorder diagnosed, but reported differentiation of symptoms was possible; mainly, alcohol use disorder was attributable to the alcohol abuse and PTSD to all other symptoms. The examiner identified the occupational and social impairment level as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner further explained that it was not possible to differentiate which impairment is caused by each mental disorder. Since the prior examination, the Veteran reported to being single since 1990 with three children, but otherwise living alone with limited social contacts and few friends. He has not spoken to his family in over 10 years and feels otherwise completely unable to maintain relationships. He has not worked since 2011. He currently reports to a therapist and psychiatrist through the VA but have not been too frequently since the pandemic began. The Veteran's ongoing PTSD symptoms include re-experiencing, avoidance, negative alterations, and reactivity. He also reported to increased sleep but unresolving fatigue. While he did experience racing thoughts and anxious feelings. The Veteran also reported to using marijuana to cope with PTSD symptoms. For VA purposes, the Veteran's diagnoses yielded the following symptoms: depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, mild memory loss, such as forgetting names, directions or recent events, 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 work like setting, inability to establish and maintain effective relationships, impaired impulse control, such as unprovoked irritability with periods of violence. Regards to behavioral observations, the examiner reported orientation within normal limits, appropriate behavior, anxious and irritable but appropriate affect and mood, communication within normal limits, and normal speech. The Veteran did not report of present or past delusions, hallucinations, or obsessions. He had appropriate thought processes and was able to understand directions and answer direct questions. He did not appear to be confused, while he did report mild memory impairment related to names, directions, and recent events. Suicidal and homicidal ideations were absent. The Veteran submitted several VA medical treatment records. Prior to the appeal period, the Veteran unsuccessfully attempted suicide, twice, in November 2011, as supported by the VA medical treatment in November 2011. While the Veteran had denied suicidal ideation, he explained that he had attempted to overdose due to issues with his now ex-spouse. In April 2012, the Veteran reported that he had received another driving while intoxicated, served time, and completed substance treatment. Previous to this record, the Veteran was regularly treated for insomnia and anxiety, but no other symptoms particularly stood out to justify a disability rating in excess of the 50 percent assigned in the appeal period prior to August 27, 2020. In 2013, the Veteran reported for various treatments but generally denied to experiencing any significant symptoms as due to PTSD and the alcohol use disorder. For example, during the December 2013 PTSD screening, the Veteran's score was negative, although the Veteran did report to having difficulty with controlling alcohol intake and seeing progressively dropping grades. During the July 2015 mental health outpatient assessment, the Veteran generally denied having any particular PTSD symptoms other than anxiety surrounding the proposal to end a prescription. In a November 2015 VA Domiciliary Note, while the Veteran continued to deny having suicidal ideation, he also did explain that he had no thoughts of self-harm, but that he could not guarantee he would not do something. A March 2018 VA treatment report supported "current suicidal ruminations." The Veteran and his representative also submitted a private medical opinion in June 2021 discussing the severity of the Veteran's PTSD symptoms. After briefly addressing the Veteran's medical history prior to service, the provider gave a brief summary of the medical evidence in the claims file. The provider also interviewed the Veteran, where the Veteran reported that he generally was functional and normal until he dropped out of high school to join the Air Force. The Veteran reported to adjusting to his duties well within the Air Force, at least until the military sexual trauma event, so much so that by October 1979, the Veteran was no longer recommended for reenlistment. The provider noted that the Veteran attempted another stint with the Navy but found it brief and "a failure" and the Veteran reported to symptoms such as anxiety in crowds, feeling of being marred, feeling blame for the event, and of becoming a "homosexual." He reported that he could not fit well into a civilian world, that he was suicide early on and seriously considered killing himself on many occasions, and that he only decided to get to the treatment in 2001 to 2002 due to the severity of the anger and progression in social isolation. The Veteran reported frequent nightmares, frequent and intense intrusive memories, and periods of dissociation. He also reported to frequent loss of control of his capacity to maintain emotional equilibrium and that he experienced persistent dysphoria, irritability, angry outbursts, insomnia, recurrent recall of the military sexual trauma event, nightmares, and steady increase in the desire for avoidance, even of those he previously found pleasurable. He thought little of himself, was frequently tired and was not comfortable in many aspects of basic day-to-day life. In general, the Veteran's symptoms consisted of the above. The provider also referred to the DSM-V with regards to the Veteran's PTSD symptoms and stating that the Veteran's PTSD did meet the DSM-V criteria for PTSD. Based on the above, the Board finds that the severity of the Veteran's reported symptoms more closely approximated occupational social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood throughout the appeal period. Impairment to mood was demonstrated as the Veteran consistently reported anxiety and depression. Impairment to family relations was demonstrated as the Veteran reported that he had not spoken to his family in many years. While the Veteran reported no suicidal ideation in the VA examinations, the Veteran's clinical records show that the Veteran was indeed was at risk for suicide multiple times during the appeal period. See Bankhead v. Shulkin, supra. As social and occupational impairment with deficiencies in most areas was demonstrated, a 70 percent rating is warranted for the appeal period prior to August 27, 2020 is warranted. However, a rating higher than 70 percent is not warranted as total social and occupational impairment was not demonstrated. Total social impairment was not demonstrated as the Veteran reported having a few friends. The Veteran has not alleged, and the record does not establish, gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. During August 2020 VA examination, the Veteran specifically denied having had any delusions or hallucinations. While the Veteran reported memory difficulties, there is no evidence or allegation of memory loss for the names of close relatives, own occupation or own name. Although the Veteran had a history of suicide attempts, the Veteran continuously denied any suicidal or homicidal ideation or attempts during the appeal period. Therefore, persistent danger of hurting self or others. Therefore, a total rating is not warranted. In assessing the severity of the PTSD, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board has also considered whether a staged rating under Fenderson v. West, supra is appropriate for the Veteran's service-connected PTSD; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning a staged rating for this disability is not warranted. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that the preponderance of the evidence is for the assignment of the initial 70 percent rating for PTSD with alcohol use disorder to August 27, 2020. To that extent, the appeal is granted. However, a rating in excess of 70 percent for PTSD with alcohol use disorder is not warranted at any point during the appeal period. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. TDIU 4. Entitlement to a TDIU is granted. Regarding the entitlement to TDIU, the Veteran's attorney submitted June 2021 statement asserting that the Veteran had not maintained substantially gainful employment throughout the appeal period due to his service-connected PTSD and therefore warranted a TDIU entitlement throughout the appeal period. 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). Rating boards should submit to the Director of Compensation Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). 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); see 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). An assessment of TDIU entitlement based on the combined effects of all service-connected disabilities should address all such disabilities. Therefore, the cumulative effects (functional impairment) of all service-connected disabilities should be addressed in determining if the service-connected disabilities prevent substantially gainful employment. Floore, 26 Vet. App. 376; accord Geib v. Shinseki, 733 F.3d 1350, 1353-54 (Fed. Cir. 2013). In making such a determination, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record and every item does not have the same probative value. The Board must analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, account for the evidence that it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad, 1 Vet. App. at 169. The Veteran's credibility affects the weight to be given to his or her testimony and lay statements, and it is the Board's responsibility to determine the appropriate weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The ultimate question is whether he is capable of performing the physical and mental acts required by employment, not whether he can find employment. 38 C.F.R. § 4.16(a); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran is currently service connected for PTSD with alcohol use disorder, now rated as 70 percent disabling throughout the appeal period. Therefore, the schedular criteria for a TDIU have been met. 38 C.F.R. § 4.16. In the June 2021 Application for Increased Compensation Based on Unemployability (VA 21-8940 Form), the Veteran reported that he had been under a doctor's care or hospitalized in the past 12 months and received treatment for his PTSD from 2015 to 2021. The Veteran reported that he had been affected in full time employment and that he last worked full-time and became too disabled to work on April 1, 2011. The most he ever earned was in 2005 as a driver. At his last position, the Veteran was employed as a cashier at the local grocery store, working 40 hours per week from July 2009 to April 2011. Other employments were of similar nature, He reported that he did not attempt to obtain employment after becoming too disabled to work. The Veteran reported to finishing high school, but that he did receive education and training after becoming too disabled to work in September 2015. The Veteran did not complete the program due to anxiety associated with college courses. A November 2019 Vocational Rehabilitation and Education correspondence indicated that the Veteran's participation was discontinued, at least partially due to the Veteran's PTSD. The rehabilitation counselor determined that the type of employment handicap the Veteran experienced was a serious employment handicap. Notably, the rehabilitation counselor determined that given the Veteran's excellent grades, as long as his personal and medical states stabilized, he would excel in coursework and employment. The Veteran also submitted a private medical opinion in June 2021. Within the report, the provider reviewed the claims file, interviewed the Veteran and completed the report. The provider noted that as due to the Veteran's PTSD resulting from in-service military sexual trauma, the Veteran has been unable to maintain or hold a steady employment. Specifically, the Veteran reported to having hundreds of jobs and never maintaining meaningful, gainful, or consistent employment. The provider noted that the Veteran's persistent and inordinate anger with thoughts of violence, irritability, poor social relationships, persistent intrusive thoughts of military sexual trauma, periods of dissociation on the job, and steady deterioration in the capacity to focus and concentrate on work or engage in reasonable task completion attributed to the Veteran's early departure, whether voluntary or involuntary. The Board has carefully considered the Veteran's statements, and the medical evidence of record, regarding the effect of his PTSD on his ability to obtain and maintain employment. The Board concludes that the Veteran experienced significant limitation as a result of his service-connected PTSD, that this disability impacted his daily functioning and earning capacity and rendered the Veteran unable to secure or follow a substantially gainful occupation. Generally, the fact that he was having impairments or difficulties does not provide a basis to grant TDIU. However, based on the evidence as discussed above, the Board notes the effects of his psychiatric limitations, to include alcohol use, criminal charges regarding his substance use, anxiety and depression, render the Veteran essentially unemployable in all employment settings consistent with his education. The Board also notes that the Veteran no longer has a driver's license. (Continued on the next page) Therefore, based on the foregoing, the Board finds that the effects of the Veteran's service-connected PTSD rendered him unable to secure and follow a substantially gainful occupation and entitlement to a TDIU is warranted. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.J. Kim, 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.