Citation Nr: 21005502 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 14-11 953 DATE: February 1, 2021 ORDER Entitlement to an initial disability rating in excess of 50 percent prior to December 9, 2016 forward for posttraumatic stress disorder (PTSD) is denied. Entitlement to a disability of 70 percent, and no higher, from December 9, 2016 forward is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) from December 9, 2016 forward is granted. FINDINGS OF FACT 1. Prior to December 9, 2016, the Veteran’s PTSD was manifest by panic attacks, difficulty in understanding complex commands, impairment of short and long-term memory, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and irritability without unprovoked outbursts of anger. 2. From December 9, 2016 forward, the Veteran’s PTSD was manifest by panic attacks, difficulty in understanding complex commands, impairment of short and long-term memory, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and irritability with unprovoked outbursts of anger. 3. As of December 9, 2016, the Veteran’s service-connected disabilities were of such severity as to render him unemployable. 4. Prior to December 9, 2016, the manifestations of the Veteran's service-connected disabilities did not prevent him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 50 percent prior to December 9, 2016 for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for Entitlement to a disability rating of 70 percent, and no higher, from December 9, 2016 forward for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for a TDIU have been met as of December 9, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1969 to February 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Saint Louis, Missouri. In a February 2020 Joint Motion for Remand, the parties determined that the Board failed to ensure compliance with an October 2015 remand. See, Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the October 2015 Board remand required that a social and industrial survey be obtained "to ascertain the Veteran's employment functioning. See, October 2015 Board Remand. In July 2020, the Board again remanded these matters for compliance with its directives. Specifically, the RO was to obtain a Social and Industrial Survey for the purposes of determining the Veteran’s eligibility for a TDIU. The Board notes that the Veteran did not respond to a request for a completed VA Form 21-8940 and that the RO obtained a VA PTSD examination in November 2020 in which the examiner commented as to the effects of the Veteran’s PTSD on his employability. accordingly, the Board hereby finds that substantial compliance with its remand directives pertaining to the Veteran's psychiatric claim has been completed. See, Stegall. 1. Entitlement to an initial disability rating in excess of 50 percent prior to November 16, 2020, and in excess of 70 percent thereafter, for PTSD. The Veteran contends that he is entitled to an initial disability rating in excess of 50 percent prior to November 16, 2020, and in excess of 70 percent thereafter. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The Board concludes that prior to December 9, 2016, the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 70 percent and that from December 9, 2016 forward, his symptoms more closely approximated the symptoms associated with a 70 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for 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; or memory loss for names of close relatives, own occupation or own name. In a May 8, 2012 statement in support of claim for service connection for PTSD, the Veteran stated that he has to "sleep with some type of light on all night...so [he] will know where [he is]...during the night and [has] flashbacks." He further endorsed having "severe panic and anxiety attacks" if his night light is not on. The Veteran was afforded a VA PTSD examination in November 2012. Diagnoses of PTSD and depressive disorder, not otherwise specified, were noted. The examiner noted that the Veteran's symptoms of re-experiencing, avoidance and hypervigilance/startle are related to his PTSD, while all other symptoms are attributed to both PTSD and depression. 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. The Veteran reported having a good relationship with his daughter, enjoying being outdoors, cooking, sports and working out. He did not endorse having any friends, but did endorse having "lady friends" he occasionally sees. He stated that after the Army he worked at a printing company for a few years, then became a truck driver before quitting within a year before going back. He then reported working at an airport before working for the post office from 1986 to 2010, when he retired. Symptoms of depressed mood, anxiety and chronic sleep impairment were noted. In a March 2013 Notice of Disagreement (NOD), the Veteran stated that he experiences panic attacks 3 to 4 times per week, has short and long-term memory problems, has "issues with understanding complex commands" and "experience[s] a high level of anger and [has] an aggressive mentality 3 to 4 times a day." He then stated that all of this affected his ability to work and asserted that he "can no longer tolerate supervisors, co-workers, or customers due to the anxiety, depression, and especially the agitation" of dealing with other people. He then stated that he has never married or had close friends due to his symptoms. A March 20, 2013 VA treatment record notes the Veteran reported that self-medicating with alcohol has helped to reduce his general stress levels. A pensive mood was noted. Chronic anxiety, poor sleep and alcohol abuse were noted. An April 16, 2013 VA psychiatric intake examination notes the Veteran reported that his mood had been up and down and that he felt anxious at times, irritable other times, and "tense" all of the time but denied any violence or aggressive behavior. He stated that he does not like being around crowds, loud noises and people as it irritates him. He then stated that he sleeps with a night light as he does not like the dark. He endorsed nightmares about Vietnam and sleeping only 4.5 hours per night. A prior history of drug and alcohol abuse was noted. An April 29, 2013 VA treatment record notes the Veteran was newly sober and reported that he "was able to handle frustration with his granddaughter without yelling at her." He reported that taking Sertraline had noticeable benefits of improving his sleep and reducing his feeling of tension. A June 19, 2013 VA treatment record notes the Veteran reported feeling calmer after taking Sertraline, but still reported some anxiety and depression, and that he "still get[s] a little upset, but he is able to catch himself and tell himself that there is no point in getting upset." He also reported an improvement in his sleep. An August 23, 2013 VA treatment record notes the Veteran reported doing much better and feeling happy. He further reported feeling calmer and happier overall, and that he was getting along well with his family. He also reported that "his family has noticed his mood and behavior changes as well." A November 27, 2013 VA treatment record notes the Veteran reported feeling "a little stressed recently", stating it was stressful living with his mother who would not go to rehabilitation after a stroke. He then stated that he and his granddaughter moved out and into their own place. He then expressed an increasing desire to be alone, stating that "he is calm and better when he is by himself." He then reported having problems staying asleep and with worry. A February 7, 2014 VA treatment record notes the Veteran reported being in a better mood since his Sertraline was increased and denied any significant depression, anxiety or other mood issues. He endorsed having "a couple of nightmares", one of which was about Vietnam. He then reported having had 2 to 3 nightmares in the prior 4 months but otherwise "is able to sleep well and without any issues." A February 18, 2014 VA treatment record notes the Veteran reported enjoying the group format of his cognitive processing therapy and expressed a desire to be more social and potentially date again. Mild PTSD was noted. A March 7, 2014 VA treatment record notes the Veteran expressed anger being around Vietnamese people, talked about seeing death for the first time in Vietnam and related an instance of a Vietnamese refugee versus American citizen gang fight when he was young. He then stated that he saw a Vietnamese person staring at him while at the VA, but did not act on his rage due to his granddaughter being present. He reported having vivid nightmares. An April 1, 2014 VA treatment record notes the Veteran reported being depressed in the 1970's and had suicidal ideation. He further "indicated symptoms of anger and irritability, nightmares, and mood changes." He stated that previous partners did not want to marry him due to his anger, fighting and drinking. He further stated that he does not go anywhere around people due to fear and anxiety and related an incident of wanting to beat someone up the previous year due to waiting in a line. He then reported having memory and attention problems. Long term memory was noted as poor, but memory and attention were noted as "adequate for the exam purposes." In his April 2014 appeal to the Board, the Veteran reported continuing social impairment, "severe panic attacks several times a week", always being on edge and having sleepless nights. A June 11, 2014 VA treatment record notes the Veteran reported being in a relationship again and that he attributed this to his being in a better mood. He stated that his girlfriend was someone he used to work with at the post office. An August 15, 2014 VA treatment record notes the Veteran reported that his mood and relationship with his granddaughter were "good" and "better." He further reported visiting family the previous month and described it as a really good time. He reported that his relationship with his girlfriend was going well. He reported going to the YMCA to work out at least 3 times per week and sleeping well, though endorsed having "a few weird dreams when he missed his Sertraline on a couple of days." A November 5, 2014 VA treatment record notes the Veteran denied any significant mood issues, major depression or anxiety. He reported missing recent group therapy sessions, noting that he prefers to be in groups with Vietnam Veterans only, but stated that he might start going again. He reported that his relationship with his girlfriend was going well and that there was no pressure at all in the relationship. He endorsed fair sleep and fair energy. A January 13, 2015 VA treatment record notes the Veteran reported doing well and denied any depression, anxiety or other mood issues. He reported spending a lot of time with his granddaughter and that he was still in a relationship with his girlfriend. He reported sleeping well and having fair energy. A March 27, 2015 VA treatment record notes the Veteran reported that "he [was] doing well" and denied any immediate issues or concerns. A September 17, 2015 VA treatment record notes the Veteran reported that he was "doing fine" and that Sertraline was "helping [him] with [his] sleep and nightmares." The Veteran's memory was described as intact as to recent and remote, with good attention and concentration. A September 29, 2015 VA treatment record notes the Veteran endorsed having little interest or pleasure in doing things for several days during a depression screen. The Veteran was afforded a VA PTSD examination in November 2015. Diagnoses of PTSD and alcohol use disorder were noted. It was further noted that the symptoms noted in the examination were "judged to be primarily related to his diagnosis of PTSD as he denies frequent or pervasive alcohol use at this time." 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. He reported having a good relationship with his granddaughter, stating that he helps her out with activities and that they go out to restaurants twice per week. reported that he had engaged in some dating, but "has not had any serious relationships since his last evaluation" and stated that he doubted he could become involved to the point of living with someone. He reported having one close friend, another Veteran, with whom he talks 2 to 3 times per week, and gets together once every 2 to 3 weeks. He stated that he mostly keeps to himself as there is always something that irritates him. He did endorse going to the YMCA 4 times per week. Symptoms of depressed mood, anxiety, disturbance of motivation and difficulty in establishing and maintaining effective work and social relationships were noted. It was noted that the Veteran was vague at times. Some difficulties based on interactions and difficulties spelling words backwards were noted. "Memory for historical information appeared grossly intact but some inconsistencies were noted." The Veteran was afforded a VA PTSD examination in November 2015. The Veteran denied working or attending school since his last evaluation and he identified the following barriers to employment. getting along with others; pain and mobility issues in his knees, numbness in his extremities; and a lack of a desire to do anything. A January 20, 2016 VA treatment record notes the Veteran reported mild bouts of on/off depression that do not last long. He also reported that his medication has helped with his sleep, anxiety and depression. A May 20, 2016 VA treatment record notes the Veteran reported bouts of mild, on/off depression that do not last long. He further reported that when he has anxiety it is accompanied by shortness of breath. He denied nightmares but endorsed waking up at night. He further endorsed isolating himself. An August 3, 2016 VA treatment record notes the Veteran reported feeling "tired a lot of the time", but also endorsed improving depression and anxiety. He further endorsed waking up at night and isolating himself, stating that he feels better alone. The Board notes that the Veteran expressed suicidal ideation in the 1970s, well prior to the period on appeal, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Veteran regularly denied thoughts, intent, or a plan involving self-harm in existing treatment records. The Board finds that, prior to December 9, 2016, the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. See 38 C.F.R. § 4.126. The evidence of record shows that the Veteran’s PTSD prior to December 9, 2016 was manifest by panic attacks, difficulty in understanding complex commands, impairment of short and long-term memory, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Board acknowledges that the Veteran did report irritability, but finds that the record reflects an initial improvement of his irritability and no evidence that he had unprovoked, angry outbursts. A December 9, 2016 VA treatment record notes the Veteran denied feeling depressed, but endorsed anxiety, irritability and angry outbursts when outside of his house. He reported crowds, bad drives, "jerks" and people in general. He stated that he "has aggressive thoughts toward people...but denies plan and intent to hurt/harm others." He did endorse verbally confronting people in public once or twice per week when they are being "obnoxious", but does not get physical. He further endorsed road rage and angry outbursts when he drives, including aggressive tailgating and passing closely. He then stated that he isolates at home to avoid his triggers. He further endorsed having nightmares at least 3 times per week and waking up 3 times per night. A December 15, 2016 VA treatment record notes the Veteran was "yelling at staff because he did not get gabapentin while in surgery" and that he refused to listen to what was being explained to him and that he keeps talking over staff". A March 9, 2017 VA treatment record notes the Veteran reported 2 to 3 short episodes of anxiety per day with no recognizable triggers. He reported continuing irritability for which he "consciously avoids negative interactions with others and walks away when he finds himself getting irritated." He avoids malls and Walmart to avoid crowds and obnoxious people. He also reported continuing road rage with tailgating but denies confronting other drivers. He stated that he sleeps up to 10 hours most nights, but still wakes up 3 times per night. He stated that his granddaughter is a positive influence in his life and that he likes seeing her happy. A July 10, 2017 VA treatment record notes the Veteran reported having a conflict with his granddaughter about her dating. He denied anxiety but endorsed getting frustrated very easily. An October 10, 2017 VA treatment record notes the Veteran reported continuing frustration with his granddaughter. A January 8, 2018 VA treatment record notes the Veteran reported continuing frustration with his granddaughter. An April 10, 2018 VA treatment record notes the Veteran reported that his granddaughter left to go live with her grandmother after a verbal altercation. He then stated that a few weeks prior he stopped taking sertraline but within a few days started thinking about his past, started crying and became depressed, leading to his restarting the medication. A July 13, 2018 VA treatment record notes the Veteran reported that his granddaughter is still living with her grandmother but that he was now spending more time with his girlfriend. He reported becoming easily frustrated. An October 11, 2018 VA treatment record notes the Veteran reported feeling "easily irritable" due to his upstairs neighbor. It was noted that he related a history "of aggression and sexual promiscuity in a fond light", but reported good control of symptoms. A January 10, 2019 VA treatment record notes the Veteran reported having nightmares since his last appointment. It was noted that though he denied any suicidal ideation, he reported a "little bit of depression" and indicated that "his granddaughter keeps him alive at this time." An April 11, 2019 VA treatment record notes the Veteran reported being irritated by his neighbors and endorsed some depression. A July 18, 2019 VA treatment record notes the Veteran was "very irritated initially", but eventually became calm. A November 7, 2019 VA treatment record notes the Veteran displayed irritated and annoyed behavior and affect. A March 12, 2020 VA treatment record notes the Veteran reported being "ticked off" and also endorsed experiencing a flashback of Vietnam. He further endorsed ongoing nightmares, though stated they are improving. A July 16, 2020 VA treatment record notes the Veteran reported that he "[c]ontinues to have problems going off on people for every little thing" and that "there is nothing between calm and going off." Significant underlying depression was noted. It was noted that the Veteran had recent suicidal ideation, though this was noted as being only transient in terms of plan. An October 15, 2020 VA treatment record notes the Veteran reported doing better with depression and anxiety, but endorsed ongoing nightmares and flashbacks. He further reported ongoing, passive suicidal ideation, but denied any thoughts of actually harming himself at this time. He did endorse occasionally feeling a desire to hurt people who behave poorly. The Veteran was afforded a VA PTSD examination in November 2020. A diagnosis of PTSD was rendered, and it was noted that while his impaired impulse control does not include physical violence, he is interpersonally impaired which contributes to road rage. Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood was noted. The Veteran reported that he broke up with his girlfriend in early 2019 and that he has not dated since. He further reported being quick to anger and that he said things belittled his girlfriend, though also stated that she stole from him which ended the relationship as he lost trust and respect for her. He reported talking with his sister every once in a while, and stated that his mother lives in a local assisted living facility. He reported some suicidal gesturing in the early 1990s, but denied any such ideation since. It was noted, however, that he expressed "a general lack of care regarding living," stating to the effect that if he dies, he dies. He endorsed the use of alcohol and cannabis. He reported that he misses his granddaughter since she moved out and has her own apartment now. Symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impaired judgment, 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 and impaired impulse control, such as unprovoked irritability with periods of violence, were noted. The Board finds that, from December 9, 2016 forward, the severity, frequency, and duration of the Veteran’s symptoms more closely approximate the symptoms contemplated by a 70 percent rating, but not those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. On December 9, 2016 the Veteran first reported irritability with angry outbursts, including regular bouts of road rage. The Board notes that the Veteran expressed suicidal and possible homicidal ideation in October and November 2020 VA treatment and examination records, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Veteran regularly denied thoughts, intent, or a plan involving self-harm or harm to others in existing treatment records, which described the ideations as passive In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 100 percent rating. The criteria for a 100 percent or higher rating are not met and the appeal must be denied. Based on the above, the Board finds that prior to December 9, 2016, the Veteran’s PTSD was manifested by panic attacks, difficulty in understanding complex commands, impairment of short and long-term memory, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. As such, the preponderance of the competent evidence is against an initial rating in excess of 50 percent prior to December 9, 2016. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Based on the above, the Board finds that from December 9, 2016, the Veteran’s PTSD was manifested by panic attacks, difficulty in understanding complex commands, impairment of short and long-term memory, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and irritability with unprovoked outbursts of anger. Resolving all reasonable doubt in the Veteran’s favor, a disability rating of 7- percent, and no higher, from December 9, 2016 is warranted. The benefit-of-the-doubt doctrine is applicable. See 38 U.S.C. § 5107 (b); Gilbert. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See, Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to a TDIU. The Veteran asserts that his service-connected disabilities render him unemployable. A TDIU may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities provided that, if there is one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16 (a). The issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the adjudicator. See, Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev'd on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Although VA must give full consideration, per 38 C.F.R. § 4.15, to "the effect of combinations of disability," VA regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner's opinion. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); 38 C.F.R. § 4.16 (a). The effective date for an increased rating for disability compensation will be the earliest date as of which it is factually ascertainable that an increase in disability occurred if a claim is received within one year from such date; otherwise, the effective date is the date of receipt of the claim. 38 U.S.C. § 5110 (b) (2) (2012); 38 C.F.R. § 3.400 (o) (2) (2017). A TDIU claim is a claim for increased compensation, and the effective date rules for increased compensation apply to a TDIU claim. See, Hurd v. West, 13 Vet. App. 449 (2000). When evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for entitlement to a TDIU will be considered to have been raised by the record as "part and parcel" of the underlying claim. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Here, the issue of TDIU was raised in a March 2013 NOD. The evidence of record shows that the Veteran reported that after the Army he worked at a printing company for a few years, then became a truck driver before quitting within a year before going back. He then reported working at an airport before working for the post office from 1986 to 2010, when he retired. The record further reflects that he has a high school education. The Veteran has been service connected for bilateral hearing loss at 0 percent and tinnitus at 10 percent since March 27, 2012. He has also been service connected for PTSD at 50 percent since March 27, 2012, and then at 70 percent since December 9, 2016. As of December 9, 2016, the Veteran has met the threshold requirement for TDIU. Turning to the next step, TDIU may be assigned where the schedular rating is less than total, when the disabled Veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Substantially gainful employment is defined as work which is more than marginal, and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). If a sufficient rating is present, then it must be at least as likely as not that the Veteran is unable to secure or follow a substantially gainful occupation as a result of that disease. See 38 C.F.R. § 4.16 (a). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The issue is not whether the Veteran can find employment generally, but whether the Veteran is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also, Van Hoose, 4 Vet. App. at 363. If total industrial impairment has not been shown, the VA is not obligated to show that a veteran is incapable of performing specific jobs in considering a claim for a total rating based on individual unemployability. See, Gary v. Brown, 7 Vet. App. 229 (1994). With the threshold requirement satisfied, the Board finds that the Veteran has shown that she was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities as of December 9, 2016. The Veteran was afforded a VA hearing loss and tinnitus examination in October 2012 and was diagnosed with bilateral sensorineural hearing loss and tinnitus. He reported having difficulty understanding speech, especially in the presence of background noise. In a March 2013 Notice of Disagreement (NOD), the Veteran stated that he experiences panic attacks 3 to 4 times per week, has short and long-term memory problems, has "issues with understanding complex commands" and "experience[s] a high level of anger and [has] an aggressive mentality 3 to 4 times a day." He then stated that all of this affected his ability to work and asserted that he "can no longer tolerate supervisors, co-workers, or customers due to the anxiety, depression, and especially the agitation" of dealing with other people. He then stated that he has never married or had close friends due to his symptoms. A June 19, 2013 VA treatment record notes the Veteran reported feeling calmer after taking Sertraline, but still reported some anxiety and depression, and that he "still get[s] a little upset, but he is able to catch himself and tell himself that there is no point in getting upset." He also reported an improvement in his sleep. An August 23, 2013 VA treatment record notes the Veteran reported doing much better and feeling happy. He further reported feeling calmer and happier overall, and that he was getting along well with his family. He also reported that "his family has noticed his mood and behavior changes as well." A December 9, 2016 VA treatment record notes the Veteran denied feeling depressed, but endorsed anxiety, irritability and angry outbursts when outside of his house. He reported crowds, bad drives, "jerks" and people in general. He stated that he "has aggressive thoughts toward people...but denies plan and intent to hurt/harm others." He did endorse verbally confronting people in public once or twice per week when they are being "obnoxious", but does not get physical. He further endorsed road rage and angry outbursts when he drives, including aggressive tailgating and passing closely. A March 9, 2017 VA treatment record notes the Veteran reported 2 to 3 short episodes of anxiety per day with no recognizable triggers. He reported continuing irritability for which he "consciously avoids negative interactions with others and walks away when he finds himself getting irritated. He also reported continuing road rage with tailgating but denies confronting other drivers. A July 18, 2019 VA treatment record notes the Veteran was "very irritated initially", but eventually became calm. A November 7, 2019 VA treatment record notes the Veteran displayed irritated and annoyed behavior and affect. A July 16, 2020 VA treatment record notes the Veteran reported that he "[c]ontinues to have problems going off on people for every little thing" and that "there is nothing between calm and going off." The Veteran was afforded a VA PTSD examination in November 2020. Regarding employability, the VA examiner found that: the Veteran has difficulty attending or is easily distracted from the task at hand; has difficulty maintaining concentration and focus on work over a period of time, tends to skip from one task to another without completing the prior task; has significant difficulty accepting supervision or receiving instruction without becoming angry; has significant difficulty remembering instructions and details of work assignments; has significant difficulty functioning around other people, has difficulty functioning as a team member, feels uncomfortable around others; that his sleep is so disrupted that he is usually fatigued at work, making concentration and focus on work assignments difficult; and has other mental health problems or symptoms that interfere significantly with his ability to work. Based on the above, the Board finds that, as of December 9, 2016, his PTSD was of such severity that he would not be able to obtain or maintain substantially gainful employment due to irritability and angry outbursts. The reflect reflects that after an initial period of improvement with his irritability, he reported on December 9, 2016 that he was having angry outbursts involving confronting people in public and engaging in road rage. The record reflects that this behavior has continued ever since. Additionally, the Board notes that he has reported having trouble understanding what other people say when background noise is present, which likely would aggravate or provide a trigger for his anger. The Board finds that, based on the Veteran’s work history and education, there is no job where the Veteran could reasonably work by himself with no supervision or coworkers. In weighing the lay and medical evidence of record, and upon resolution of all reasonable doubt in the Veteran's favor, the Board finds that as of December 9, 2016, the Veteran was unemployable due to his service-connected disabilities, and that a grant of TDIU is warranted as of that date. The Board has also considered whether the matter warrants referral for consideration of an extraschedular TDIU rating for the period prior to December 9, 2016. However, in this case, the record does not show that the Veteran’s service-connected disabilities were of such severity to preclude substantially gainful employment. In October 2020, the Veteran was provided with a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability (a form designed to obtain necessary information about a claimant's disabilities and employment and educational histories, see VA Adjudication Manual M21-1 IV.ii.2.F.2.b.). Unfortunately, the Veteran did not return this completed form to support his claim. As such, the Board finds that, prior to December 9, 2016, the evidence of record does not include sufficient information to refer the matter of TDIU for extraschedular consideration. C. TRUEBA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Brian P. Keeley 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.