Citation Nr: 21010783 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 16-11 630 DATE: February 25, 2021 ORDER Entitlement to an increased disability rating for post-traumatic stress disorder (PTSD) in excess of 30 percent before December 10, 2019 and in excess of 50 percent thereafter, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU), effective January 25, 2016, but not earlier, is granted. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran’s PTSD symptoms before December 10, 2019 did not more closely approximate occupational and social impairment with reduced reliability and productivity. 2. The severity, frequency, and duration of the Veteran’s PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas at any time during the period on appeal. 3. From January 25, 2016, but not earlier, the Veteran’s service-connected disabilities alone prevented him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for PTSD before December 10, 2019 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 a disability rating in excess of 50 percent 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. 3. The criteria for a TDIU have been met as of January 25, 2016, but not earlier. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from July 1968 to July 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO); this case is in the Board’s legacy appeals system. The Veteran testified at a June 2019 Board hearing before the undersigned; a transcript is associated with the claims file. 1. Entitlement to an increased disability rating for post-traumatic stress disorder (PTSD) in excess of 30 percent before December 10, 2019 and in excess of 50 percent thereafter The Veteran contends that his PTSD symptoms are more severe than is compensated by his current disability rating of 30 percent before December 10, 2019 and 50 percent thereafter. The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher before December 10, 2019 or 70 percent or higher thereafter.   Law 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). 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. Evidence In October 2014 the Veteran’s wife described him as withdrawn, angry, distrusting, hypervigilant, and prone to explosive angry outbursts. She said he had night terrors, startle/fear response to noises like muskets at a parade, and always checked to make sure doors and windows were locked. At the same time the Veteran described flashbacks and poor sleep. He said he avoided parades and fireworks because exposure to those things made him sink into himself, unable to talk to anyone for hours. He also mentioned to his primary care doctor that he had problems with rage, irritability, excessive drinking, and nightmares when he returned from Vietnam, but his wife and family had been a reliable source of support. He admitted to current avoidance of crowds and hypervigilance which he described as “normal for me.” He declined a referral to counseling because he was worried that talking about his trauma could increase his symptoms. In February 2015 VA provided an examination to determine the severity of the Veteran’s PTSD symptoms. The Veteran described an excellent home life with his wife of 43 years and their children. He had close friends with whom he enjoyed socializing. He reported working for the United States Postal Service and then a phone company until he retired in 2009. He did not report any problems with his employment. On examination the Veteran exhibited PTSD criteria and symptoms including: recurrent, involuntary, and intrusive distressing memories of his stressor; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the stressor; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; hypervigilance; exaggerated startle response; chronic sleep disturbance/sleep impairment, and; anxiety. The examiner opined that the Veteran’s symptoms caused 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. In March 2016 VA provided an examination to determine the severity of the Veteran’s PTSD symptoms. The Veteran reported no significant updates since his February 2015 VA exam, but mentioned that when his whole family was together, including several grandchildren, he sometimes needed to leave the room to avoid the noise and crowding. There was no change in his employment history, but the Veteran mentioned that his primary reasons for retiring in 2009 were irritability and anxiety on the job. He reported his symptoms as worsening since that time but is better able to avoid triggering stimuli. He reported current symptoms including: avoiding large crowds, loud noises, tight spaces, traffic, and air travel; irritability, better controlled over the past few years; anxious thoughts of being boxed, trapped, or lowered into the ground in a coffin; daily intrusive thoughts of a friend who died in Vietnam, including feelings of guilt and sadness; and poor sleep with anxiety if he is too tightly covered because this mimics the feeling of being trapped. On examination the Veteran exhibited PTSD criteria and symptoms including: recurrent, involuntary, and intrusive distressing memories of his stressor; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of his stressor; marked physiological reactions to internal or external cues that symbolize or resemble an aspect of his stressor; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the stressor and external reminders that may arouse those memories, thoughts, or feelings; persistent, distorted cognitions about the cause or consequences of the stressor that lead the Veteran to blame himself or others; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; hypervigilance; exaggerated startle response; chronic sleep disturbance/sleep impairment, and; anxiety. The examiner stated that the Veteran experiences daily trauma related anxiety that would probably impair or significantly limit his ability to perform in an occupational setting. However, because the of tremendous family support (especially his wife), a learned ability to modulate his anxiety, tendency to isolate at times, his avoidance of stressors and trauma triggers, his engagement in hobbies, and positive coping mechanisms, the Veteran is able to function at higher levels and reports high life satisfaction. The examiner opined that the Veteran’s symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. On his March 2016 Form 9 the Veteran stated that his VA examinations were inadequate. He stated that he does not have long conversations with anyone, that he stays quite in groups and has trouble following conversations. He also reported forgetfulness, difficulty understanding and following instructions, difficulty learning to use electronics, moodiness, quick temper, and anxiety if he stays too long with a friend or family member. In September 2017 VA provided an examination to determine the severity of the Veteran’s PTSD symptoms. The Veteran reported a long pattern of not developing relationships beyond acquaintances and standing away from groups. He reported an excellent relationship with his wife and strong support from her and his family. There was no change to his employment history and the Veteran reported working for 38 years as a cable splitter, where he preferred to work in isolation but could work with others when necessary. His wife described his “road rage” and said he copes with stressful family moments by withdrawing. On examination the Veteran exhibited PTSD criteria and symptoms including: recurrent distressing memories, distressing dreams; dissociative reactions/flashbacks; intense or prolonged psychological distress at exposure to triggers/cues; avoidance of memories and cues; persistent exaggerated negative beliefs; persistent negative emotional state; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable/angry behavior with outbursts; hypervigilance; exaggerated startle response; problems with concentration; chronic sleep disturbance/sleep impairment, and; anxiety. Regarding employability, the examiner noted the Veteran was subject to distractibility but denied impact on sustaining concentration for completion of tasks, intrusive thoughts, or capacity to work with a team when necessary. Objective testing revealed a PTSD PCL-5 score within normal limits, Zung self-rated anxiety scale score within normal limits, and CES-Depression Scale score subthreshold for major depression with only mild symptom endorsement. The examiner opined that the Veteran’s symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. At his June 2019 Board hearing the Veteran had trouble speaking about his PTSD and related symptoms. His wife described the Veteran’s consistent difficulty discussing his trauma with anyone and said his symptoms, especially night terrors, were getting worse. She also said discussing his trauma often leads to increased intrusive memories and related irritability, which can be especially problematic with kids around the house. In December 2019 VA provided an examination to determine the severity of the Veteran’s PTSD symptoms. Veteran reported that he has “outbursts” when he is irritated and stated he gets loud and needs time to himself. He reported anger issues, poor concentration with a tendency to fall asleep while reading, poor sleep, overall mood as ok but his wife tells him that he can be moody. He had limited relationships outside of his immediate family and engaged in few activities, mainly spending the day accompanying his wife to her activities. There was no change to his employment history. On examination the Veteran exhibited PTSD criteria and symptoms including: recurrent, involuntary, and intrusive distressing memories and dreams of his stressor; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of his stressor; marked physiological reactions to internal or external cues that symbolize or resemble an aspect of his stressor; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with his stressor and external reminders that may arouse those memories, thoughts, or feelings; persistent, distorted cognitions about the cause or consequences of his stressor that lead the individual to blame himself or others; persistent negative emotional state; irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression; hypervigilance; exaggerated startle response; problems with concentration; chronic sleep disturbance/sleep impairment; anxiety; suspiciousness; panic attacks (no more than weekly); mild memory loss; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships, and; difficulty in adapting to stressful circumstances, including work or a work-like setting. Regarding employability, the Veteran reported that difficulties with his legs, headaches, and his PTSD symptoms interfered with his ability to continue to work. He said his concentration issues impacted his ability to work with small wires and he had trouble coping with unspecified work-related stressors. The examiner stated that the veteran maintained moderate impairments in interpersonal relationships, moderate impairments in coping with stress, and moderate impairments in motivation and drive due to his service-connected PTSD that would likely impair his ability to function in any sedentary or physical employment setting. The examiner opined that the Veteran’s PTSD symptoms caused occupational and social impairment with reduced reliability and productivity. Analysis Before December 10, 2019 The Board concludes that before December 10, 2019, the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 50 percent or higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 30 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 30 percent rating. VA treatment records, three VA examinations from February 2015 through September 2017, and the Veteran’s lay statements show that the Veteran’s PTSD was manifested by symptoms associated with a 30 percent rating including anxiety and chronic sleep impairment, symptoms associated with a 50 percent rating including difficulty in establishing and maintaining effective work and social relationships, and symptoms associated with a 70 percent rating including impaired impulse control. He also had symptoms that are not listed with a specific rating, addressed below. Based on the Veteran’s report of his performance level at work before he retired, his and his wife’s lay statements, and his medical records, the Board finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 30 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 50 percent rating. See 38 C.F.R. § 4.126. The Veteran reported that he could function socially and at work before his retirement, with some difficulty, and his symptoms would increase in severity when he had to engage in prolonged conversation, encountered a triggering stimulus, or had to think about or discuss his stressors. Further, intrusive thoughts and avoidance of those thoughts and related stimuli, diminished interest or participation in significant activities, feelings of detachment or estrangement from others, hypervigilance, exaggerated startle response, persistent distorted cognitions about the cause or consequences of his stressor, persistent negative emotional state/inability to experience positive emotions, and trouble with concentration are similar to depressed mood, anxiety, suspiciousness, panic attacks, and mild memory loss, which are contemplated by the assigned 30 percent rating. The remaining symptom of irritability with angry outbursts is similar to either impaired judgment or impaired impulse control, which are listed symptoms for 50 and 70 percent ratings, respectively. The Board notes that the record does not show any instances of physical violence during these outbursts and that outside of a general description of “road rage” the Veteran emphasized his withdrawal from situations more than his angry responses. The Board also finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 30 percent rating. The Veteran was retired during the period on appeal but reported engaging in hobbies and work around the house. He had limitations in his social interactions but was able to maintain an excellent relationship with his wife and immediate family and accompany his wife to errands and social functions. This reflects occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but generally functioning satisfactorily, with routine behavior, self-care, and normal conversation. The Board notes that “normal conversation” here is compared to speech that is at least intermittently circumstantial, circumlocutory, stereotyped, illogical, obscure, or irrelevant. It does not imply that the Veteran had no difficulty with conversation. Mental status examinations in VA and private treatment records and the three VA examinations from February 2015 through September 2017 indicate that the Veteran was alert and oriented to person, place, and time and had a sometimes muted, but not flattened, affect. While the Veteran did experience symptoms contemplated by a 50 and 70 percent ratings— difficulty in establishing and maintaining effective work and social relationships and impaired impulse control —the evidence overall does not demonstrate the level of impairment associated with a 50 percent rating. As noted above, the Veteran’s other remaining symptoms were either contemplated by or more consistent with a 30 percent rating. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms before December 10, 2019 resulted in the level of impairment required for a 50 percent rating. The criteria for a 50 percent or higher rating before December 10, 2019 are not met and that portion of the appeal must be denied. December 10, 2019 Onward The Veteran’s PTSD is currently rated 50 percent disabling effective December 20, 2019. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. VA treatment records, the December 2019 VA examination, and the Veteran’s lay statements show that the Veteran’s PTSD was manifested by symptoms associated with a 50 percent or lower rating including anxiety, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships, panic attacks (no more than weekly), mild memory loss, flattened affect, and disturbances of motivation and mood; and symptoms associated with a 70 percent rating including difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a work-like setting. He also had symptoms that are not listed with a specific rating, addressed below. The Board finds 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. Further, intrusive and distressing thoughts, avoidance of those thoughts and related stimuli, hypervigilance, exaggerated startle response, persistent distorted cognitions about the cause or consequences of his stressor, persistent negative emotional state/inability to experience positive emotions, and trouble with concentration are similar to depressed mood, anxiety, suspiciousness, panic attacks, and mild memory loss, which are contemplated by the assigned 50 percent rating. The remaining symptom of irritability with angry outbursts is similar to either impaired judgment or impaired impulse control, which are listed symptoms for 50 and 70 percent ratings, respectively. The Board also finds the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with a 50 percent rating. The Veteran was retired for the period under consideration but described social impairment with reduced reliability and productivity. He maintained good relationships with his immediate family and accompanied his wife to errands or events but reported reduced participation in outside activities and limited relationships outside of his immediate family. The December 2019 VA examiner opined that the Veteran had moderate impairments in interpersonal relationships, moderate impairments in coping with stress, and moderate impairments in motivation and drive due to his service-connected PTSD which caused occupational and social impairment with reduced reliability and productivity. While the Veteran did experience symptoms contemplated by a 70 percent rating— difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and possibly impaired impulse control—the evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran’s other remaining symptoms were either contemplated by or more consistent with a 50 percent rating. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms from December 10, 2019 onward resulted in the level of impairment required for a 70 percent rating. The criteria for a 70 percent or higher rating are not met and that portion of the appeal must be denied. 2. Entitlement to a total disability rating based on individual unemployability (TDIU), effective January 25, 2016 The Veteran is seeking a TDIU. He asserts that his service-connected disabilities alone prevented him from securing or following a substantially gainful occupation since his retirement in August 2009. While the Veteran’s formal claim for TDIU was only received in August 2017, his original claim for service connection for PTSD was received in October 2014. Because the Veteran appealed his initial disability rating for PTSD and pursued that claim for an increased initial rating up until the decision in the previous section, the claim for a TDIU is part and parcel of the increased rating claim and the period on appeal begins when the first claim was received on October 23, 2014. Law VA will grant TDIU when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with their education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. There are two regulatory subsections that allow for a TDIU. The first, called a “schedular TDIU,” is found at 38 C.F.R. § 4.16(a) and requires that certain disability rating percentages be in place. Either the Board or the agency of original jurisdiction (AOJ) can grant a schedular TDIU in the first instance. The second, called an “extraschedular TDIU,” is found at 38 C.F.R. § 4.16(b). It does not have the percentage requirement but cannot be granted by the Board or the AOJ in the first instance. Instead, it must be submitted to VA’s Director, Compensation Service in the first instance. 38 C.F.R. § 4.16(b). The schedular TDIU subsection provides that a total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of meeting the above rating requirement for a single disability, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. The effective date for a TDIU cannot be earlier than the effective date of service connection for the underlying disability or disabilities upon which the TDIU is based. Delrio v. Wilkie, 32 Vet. App. 232, 248 (2019). Marginal employment shall not be considered substantially gainful employment for purposes of entitlement to TDIU. Id. Marginal employment generally shall be deemed to exist when a veteran’s earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Id. Marginal employment may also be established, on a facts-found basis, when earned annual income exceeds the poverty threshold, including but not limited to employment in a protected environment such as a family business or sheltered workshop. Id. Consideration must be given in all claims to the nature of the employment and the reason for termination. Id. The extraschedular subsection explains that it is the established policy of the Department of Veterans Affairs that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation Service, for extra-schedular 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 § 4.16(a). The rating board will include a full statement as to the veteran’s service-connected disabilities, employment history, educational and vocational attainment and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). Evidence Initially, the Board reflects that the Veteran’s service-connected disabilities were evaluated as follows throughout the appeal period: Beginning October 23, 2014 PTSD rated 30 percent, right leg shrapnel wound residuals rated 10 percent (Diagnostic Code 5315), residuals of fracture of both mandibles rated 20 percent, tinnitus rated 10 percent, right lower extremity scar rated 10 percent, and residuals of right leg shrapnel wound with stiffness in right knee and degenerative arthritis (Diagnostic Code 5003-5260), hearing loss, residuals of gunshot wound lacerations to the scalp and left chest wall, scars of the right mandible and right lower extremity, and hearing loss, all rated at 0 percent, for a combined total disability rating of 60 percent; beginning January 25, 2016, the Veteran was granted service connection for migraines rated at 50 percent and his combined disability rating increased to 80 percent; beginning August 8, 2017 the Veteran’s right leg shrapnel wound residuals rating was increased to 30 percent (Diagnostic Code 5315), his residuals of right leg shrapnel wound with stiffness in right knee and degenerative arthritis rating was increased to 10 percent (Diagnostic Code 5003-5260), and his combined disability rating increased to 90 percent; beginning December 10, 2019 the Veteran’s PTSD rating was increased to 50 percent but this had no effect on his combined disability rating. The Veteran reported working as a cable splitter for Verizon for approximately 38 years, with an unspecified period working for the US Postal Service (USPS) during a time when he was laid off from Verizon. The Veteran reported retiring from Verizon in August 2009. He did not provide any details on the time or location of his time working for the USPS and Verizon sent a letter in September 2017 stating they could not locate any records for an employee by the Veteran’s name. The Board finds the Veteran’s report of his employment credible and the specific details of his employment not essential to this decision as the period on appeal begins several years after the Veteran’s last reported date of employment. In addition to the VA examinations for PTSD discussed in the previous section of this decision, the in February 2016 VA provided examinations for hearing loss and tinnitus, muscle injuries, knee and lower leg conditions, migraines, and scars. A February 2016 VA examiner diagnosed bilateral sensorineural hearing loss and tinnitus. While the Veteran’s hearing loss was rated 0 percent disabling based on the tables set in the rating schedule, the Veteran did report difficulty hearing with background noise, needing to ask for repetitions during conversations, and sounds sounding “dull.” He also reported being bothered by constant ringing in his ears. A February 2016 VA examiner noted an injury to muscle group XIV, quadriceps. The Veteran reported right knee pain while climbing stairs and kneeling, as well as his right thigh feeling weaker than his left. On examination the Veteran had consistent weakness (4/5) on his right thigh. The examiner opined this injury caused no functional impact. A February 2016 VA examiner diagnosed bilateral knee arthritis with residuals of shrapnel wound to the right knee and right knee stiffness. On examination the Veteran had full range of motion in both knees but there was pain in the right knee with motion and with weight bearing. The right knee was also tender to palpation and had reduced muscle strength (4/5) on all motions. Stability was normal. The examiner opined these conditions caused no functional impact. A February 2016 VA examiner identified one scar on the Veteran’s right lateral lower thigh that was intermittently painful with use of the knee. The scar was stable and measured 4 cm by 3cm. A February 2016 examiner diagnosed migraine headaches with characteristic prostrating attacks of migraine headache pain productive of severe economic inadaptability. The Veteran reported headaches occurring up to five times per week, usually lasting less than a day but sometimes longer. More severe headaches occurred approximately once every three weeks. Symptoms included constant pulsating or throbbing head pain which worsened with physical activity, nausea, sensitivity to light and sound, changes in vision, and sometimes sinus pressure and congestion. The examiner noted that the Veteran had to retire early at age 61 because of the pain. In August 2017 and September 2017 VA provided examinations to determine the severity of the Veteran’s knee and lower leg conditions, muscle injury, migraines, and scars. Examination of the knees showed right knee flexion reduced to 0-120 degrees with evidence of crepitus and pain on weight bearing. Strength and stability were normal. The Veteran complained of stiffness and severely increased pain with climbing stairs or prolonged walking. The examiner noted difficulty with pain and prolonged walking or standing. Examination for migraines showed mostly the same symptoms as the previous examination with the addition of sensory changes such as “pins and needles.” The Veteran reported severe headaches now occurred one to three times per month and lasted approximately two days each. He noted that when he worked he used to be able to endure the pain after taking ibuprofen. This examiner opined that the Veteran did not experience prostrating attacks of migraine headache pain, although they did not provide any rationale explaining why symptoms apparently increasing in severity and frequency since the February 2016 examination supported this conclusion. Examination for scars showed only the one scar on the Veteran’s right leg which was either painful or unstable. The examiner noted that the pain contributed to the Veteran’s trouble with prolonged standing. Examination of the Veteran’s right quadriceps showed muscle atrophy over the Veteran’s right knee and loss of muscle substance causing fatigue and pain. The examiner noted this contributed to the Veteran’s trouble with prolonged standing and walking. In June 2019 the Veteran testified that he could not work because of a combination of his migraine pain, trouble with concentration, and pain with prolonged standing or walking. He said that when he had migraines he needed to be in a quiet, darkened room and lie down. Analysis In October 2014 the Veteran’s combined disability rating was no higher than 60 percent and no individual disability was rated 60 percent disabling. However, all of the Veteran’s service-connected disabilities at that time were incurred from a single combat related injury, specifically when a truck he was in ran over a mine and flipped, pinning him underneath. The Veteran’s hearing loss and tinnitus have been linked to the noise of the explosion, his leg injuries and scars came from related shrapnel, his mandibles were broken by the impact, and his PTSD stressor is this incident. The Veteran’s service-connected disabilities are therefore considered a single disability for purposes of determining whether the Veteran had a single disability rated 60 percent or higher. See 38 C.F.R. § 4.16(a). The Veteran is therefore potentially eligible for a schedular TDIU for the entire period on appeal. However, as will be discussed below, the evidence of record shows that the Veteran’s level of impairment did not become severe enough to prevent his securing or following substantially gainful employment until January 25, 2016, the date of service connection for his migraines. The record contains no statements from the Veteran or other relevant evidence contemporaneous with his employment or retirement. In his several post-retirement statements describing his reasons for retiring the Veteran focused on his migraines and on his PTSD symptoms. He stated that he had trouble concentrating and that while he could mostly work by himself, he sometimes had trouble interacting with co-workers. While his leg pain was also a factor, it was not the focus of his statements, and he did not mention hearing or tinnitus symptoms in relation to work problems. The Veteran did not describe any incidents of disagreements or fights with coworkers and did not report ever experiencing any discipline or official negative consequences at work as a result of his PTSD or other service-connected disabilities, and the VA examiners during this period all reported symptoms that would certainly cause difficulty working but not prevent it altogether. The Board acknowledges that the Veteran’s multiple service-connected disabilities, all the result of a single in-service incident, were ratable at 60 percent, which indicates a significant impact on his ability to work. However, a high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The preponderance of the evidence does not show that the Veteran was unable to secure or follow a substantially gainful occupation based solely on the effects of the disabilities that were granted service connection before January 25, 2016. From January 25, 2016, the Board finds that the effects of the Veteran’s service-connected migraines, combined with the previously service-connected disabilities discussed above, prevented the Veteran from securing and following a substantially gainful occupation. The headaches alone, rated 50 percent disabling based on frequent prostrating attacks that required shutting himself in a dark, quiet, room for a day or more, up to three times per month, would already lead to significant problems with absenteeism from work. Adding that to the Veteran’s trouble with prolonged standing and walking and his PTSD-related trouble concentrating on tasks and learning new information and the Veteran would not have been able to continue at his previous job reasonably acquire the skills necessary to perform a less physically demanding one. The Board acknowledges the Veteran’s reports that he had migraine headache symptoms before he retired and that these symptoms contributed to his decision to retire early. However, because the effective date for a TDIU cannot be earlier than the effective date of service connection for the underlying disability or disabilities upon which the TDIU is based, the Board cannot consider the Veteran’s migraine symptoms in support of a TDIU before January 25, 2016. See Delrio, supra at 248. Because the preponderance of the evidence shows that the Veteran’s service-connected disabilities along prevented him from securing or following a substantially gainful occupation from January 25, 2016, but not earlier, the   Veteran’s claim for a TDIU is granted from January 25, 2016, but not earlier. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Zimmerman 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.