Citation Nr: 21025009 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 16-20 030 DATE: April 27, 2021 ORDER Entitlement to service connection for a low back disability is denied. Entitlement to an increased evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to total disability rating based on individual unemployability (TDIU) due to service-connected disabilities from March 27, 2013 to September 1, 2014, is granted. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran’s low back disability was related to his active duty service. 2. The Veteran’s PTSD symptoms have not manifested in severity that results in total occupational and social impairment. 3. Resolving all reasonable doubt in favor of the Veteran, the evidence of the record reasonably demonstrates that the Veteran’s service-connected disabilities from March 27, 2013 to September 1, 2014, render the Veteran unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for Veteran’s low back disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103(a), 5103A; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309. 2. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. § 1155, 5103, 5107, 38 C.F.R. § 3.102, 3.159, 4.7, 4.124(a), 4.130, DC 9411. 3. The criteria for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities from March 27, 2013 to September 1, 2014, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in active duty service with the Army from February 2003 to May 2004 to include service with the Reserves. This matter is on appeal from an October 2013 rating decision. The Veteran was afforded a May 2019 hearing before the undersigned Judge. A transcript of the hearing has been associated with the claims record. The Board remanded this appeal in September 2020 for additional development. The Board notes that in the September 2020 Board decision, the issues on appeal before the Board was entitlement to service connection for a low back disability; an increased rating in excess of 30 percent for posttraumatic stress disorder (PTSD) from June 13, 2012 to July 11, 2014; an increased rating in excess of 50 percent for PTSD from July 11, 2014 to August 31, 2015; an increased rating in excess of 70 percent for PTSD from August 31, 2015; and entitlement to a total disability based on individual unemployability (TDIU) prior to August 31, 2015. During the pendency of the appeal, a November 2020 rating decision granted a 70 percent evaluation for the Veteran’s PTSD effective from June 13, 2012, and TDIU effective from September 1, 2014. As this increase did not constitute a full grant of the benefit sought for the entire appeal period, the Veteran’s claim for a higher evaluation remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). As such, the Board has recharacterized the issues on appeal with the Board as entitlement to service connection for a low back disability; entitlement to an increased rating in excess of 70 percent for PTSD; and entitlement to TDIU prior to September 1, 2014. Service Connection Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d). Alternately, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Certain chronic diseases, including arthritis, may be service connected if manifested to a degree of 10 percent disabling or more within one year after separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In relevant part, 38 U.S.C. § 1154 (a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. 38 U.S.C. § 5107 (b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Low back disability The Veteran contends that his low back disability is related to his active duty service. Review of the medical treatment record shows treatment and surgery for the Veteran’s back disability. A November 2020 VA examiner diagnosed the Veteran with lumbosacral strain and intervertebral disc syndrome (IVDS). As such, the Board finds the Veteran with a current disability. Review of the Veteran’s service treatment records (STRS) shows in a February 2003 Reserve medical examination the Veteran did not report recurrent back injury. In a March 2004 post-deployment examination, the Veteran reported swollen or painful joints but denied back pain or muscle aches. In an April 2004 Reserve examination, the Veteran was found to have a normal spine upon examination. The Veteran reported recurrent back pain but explained that in 1997 he suffered an injury to his back while working in a warehouse and periodically experience pain. In February 2012 an MRI test found mild lumbar spondylosis with a left disc protrusion and the Veteran underwent a surgical procedure for a hemilaminectomy with microdiscectomy. The Board notes the Veteran reported undergoing additional surgeries in 2013, 2014 and 2015. In June 2013 the Veteran report back pain that began within the past 10 years. The Veteran noted that he currently works for the US Post-Office and his duties involved carrying weights up to 75 pounds; the Veteran indicated that a “third surgery is definitely going to happen to fuse his lower spine.” In an August 2013 Social Security Administration (SSA) report, the Veteran reported suffering an injury to his back while deployed to Iraq; the Veteran stated that he never sought medical attention because he was in a position of leadership; cared for his men; and believed he could “soldier through it.” The Veteran stated later on he learned that he had a ruptured disc that did not heal properly with “bone that grew around it.” In an October 2013 notice of disagreement, the Veteran stated that he suffered a fall during active duty where he landed on his back but did not receive treatment at the time. In a September 2015 hearing with a decision review officer (DRO), the Veteran testified that he sent emails to his family regarding his back. The Veteran stated that 3 to 4 weeks into a deployment in Iraq while setting up a water purification unit, the stairs were not secured, causing the Veteran fall 7 to 8 feet flat on his back. The Veteran testified that he did not seek medical attention at the time because at the time he had young soldiers under his command in the unit and “I had a job to do…” The Veteran stated there was pain but not to the point where he was unable to function; the Veteran stated the “adrenaline running through constantly…[allowed the Veteran] to push on and take care of my job.” The Veteran stated that his back had nagged him constantly since his return; the Veteran stated that he went through several jobs before finding consistent work with the post-office. The Veteran stated that he began to seek treatment when he would have periods where he was unable to stand up straight or stand at all; the Veteran indicated that after the Christmas season in 2011 “my back got to the point to where I couldn’t stand, stand up straight, and I went to seek medical treatment” and later surgery. In March 2018 the treating provider noted the Veteran underwent back surgery with a private neurosurgeon. The Veteran stated this treatment was due to a fall in 2003 while in the military. In the Veteran’s May 2019 hearing, the Veteran testified that while setting up a water purification unit, a member of his unit did not secure the stairs, causing the Veteran to fall backwards 9 to 10 feet to the ground. The Veteran stated there was pain but he did not have the opportunity to go to sick call because his unit was undermanned and “losing a sergeant, a squad leader…puts the mission in jeopardy”; the Veteran also stated that sick call within his battalion only provided Motrim for treatment and that “my back hurting doesn’t really cut it, it gets you to the front lines.” The Veteran stated that when he was seen for treatment with his first doctor, the doctor told him that bone or calcium had started to form around the ruptured disc and “that doesn’t happen overnight.” The Veteran was afforded a November 2020 VA examination. The examiner diagnosed the Veteran with lumbosacral strain and IVDS. The examiner found no evidence of arthritis and did not diagnosis the Veteran with arthritis. The Veteran reported that he fell from an unsecured ladder in 2003, given Motrim, and received no other treatment. The Veteran indicated that he had another injury during a mortar attack but did not specify any details on this event. The Veteran stated that he did not seek medical attention until 2009. The Veteran noted that following his separation from service he worked for the US Post-Office for 10 years, seeking medical attention 10 to 15 times for his back, several back surgeries, and was medically retired. The examiner found it was less likely than not that the Veteran’s low back disability was incurred in or caused by the claimed in-service injury, event or illness. The examiner noted the Veteran served in active duty from February 2003 through May 2004, and at the pertinent separation examination held in April 2004, the examining provider found a normal clinical evaluation even though the Veteran reported recurrent back pain. The examiner noted that the Veteran did not seek treatment until 2009 and therefore there was no evidence of seeking treatment for his back within a year of his separation from service. The examiner also noted the Veteran worked for the US Post-Office as a mail carrier for 10 years and opined this was an “occupation that would be difficult to perform for 10 years if there was significant back pain and dysfunction.” The examiner also noted that in the July 2013 surgical procedure for spinal fusion, the treating surgeon noted the onset of the injury was in May 2013 and therefore indicating the prior conditions were acute and transitory. After review of the evidence, the Board finds the preponderance of the evidence is against a finding that the Veteran’s low back disability is related to his active duty service. The Board notes that service connection may be granted on a presumptive basis for certain chronic diseases, including arthritis, if such disease is shown to be manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Veteran has stated that he had continuing back symptoms starting during his active duty service and continuing through his separation. In this instance however, service connection for a back condition on a presumptive basis is not warranted as the record does not show evidence of degenerative disc disease or arthritis of the lumbar spine arose during the Veteran’s period of active military service, or within one year of separation from active duty service. Notably, review of the medical treatment record does not show any findings or diagnosis of arthritis, and the November 2020 VA examiner did not find arthritis of the back. As such, the available medical evidence does not support or show that the Veteran’s back condition was present to a compensable degree within a year of the Veteran’s separation from service. Accordingly, service connection for a back disability on a presumptive basis is not warranted as a chronic disease did not manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. The November 2020 VA examiner provided a detailed review and examination of the appellant’s claims file, made repeated references to pertinent past records to include the appellant’s STRs, and statements consistent with the evidence of record. As such, the Board finds that the November 2020 VA examination report and medical records documenting the nature and extent of the appellant’s low back disability, to be the most probative evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As there have been no other probative medical opinions submitted in support of the Veteran’s claim, the November 2020 opinion is the only probative opinion of record addressing the etiology of the Veteran’s claimed issue. The Board acknowledges the Veteran’s statements and assertions that low back disability are related to his military service. Certainly, he is competent to describe experiencing symptoms. To the extent that the Veteran contends that a medical relationship exists between his claimed current disability and service the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) Nevertheless, a lay person, the Veteran does not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Here, the VA examiner considered the Veteran’s statements and reports of symptoms. The examiner still found that it was unlikely that his reported in-service symptoms were related to any current disability. The Board finds that the Veteran’s opinion is outweighed by the competent opinion of the VA examiner. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Based on the above, the Board finds that the competent evidence on record is against a finding of service connection for the Veteran’s low back disability. Review of the Veteran’s active duty STR show no complaints, treatment or diagnosis of a low back disability. Review of the medical treatment record shows the earliest competent documentation of the Veteran’s low back disability is in 2012, many years after separation from active duty service. Significantly, the only medical opinion addressing the etiology of the Veteran’s low back disability is the November 2020 opinion. The November 2020 VA examiner considered the Veteran’s report of symptoms but provided analysis of the case record to support their opinion that the Veteran’s current low back disability was less likely than not incurred in or caused by the Veteran’s active duty service. The Board thus finds that the weight of the competent and probative evidence is against a finding of service connection for the Veteran’s low back disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Posttraumatic stress disorder (PTSD) The Veteran is currently service connected for PTSD evaluated at 70 percent under Diagnostic Code 9411. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on the social and occupational impairment, rather than solely on the examiner’s assessment of the level of disability at the time of examination. The rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Lastly, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. See 38 C.F.R. § 4.130, DC 9411. The “such symptoms as” language means “for example,” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. The evidence considered in determining the level of impairment for psychiatric disorders under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the rating code. Disability ratings are assigned according to the manifestation of particular symptoms, but the use of the term “such as” in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the evidence considered in determining the level of impairment from psychiatric disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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 solely on the basis of social impairment. 38 C.F.R. § 4.126 (2020). The Board notes that one factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the “psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness.” Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect some mild symptoms [e.g., depressed mood and mild insomnia] or some difficulty in social, occupational, or school functioning [e.g., occasional truancy, or theft within the household], but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more moderate symptoms [e.g., flat affect and circumstantial speech, occasional panic attacks] or moderate difficulty in social, occupational, or school functioning [e.g., few friends, conflicts with peers or co- workers]. Scores ranging from 41 to 50 reflect serious symptoms [e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting] or any serious impairment in social, occupational or school functioning [e.g., no friends, unable to keep a job]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication [e.g., speech is at times illogical, obscure, or irrelevant] or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood [e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school]. VA has changed its regulations, and now requires use of DSM-5 effective August 4, 2014. Among the changes, DSM-5 eliminates the use of the GAF score in evaluation of psychiatric disorders. The change was made applicable to cases certified to the Board on or after August 4, 2014; and is not applicable to cases certified to the Board prior to that date. 79 Fed. Reg. 45093 (Aug. 4, 2014). As the Veteran’s case was certified to the Board after August 4, 2014, DSM-5 applies, and GAF scores are no longer used in evaluation of psychiatric disorder. Id. However, the examiner’s discussion of symptoms associated with any assigned score would still be useful in evaluation of psychiatric disabilities. Review of the medical treatment record shows in a June 2012 initial encounter for transitioning care, the Veteran reported he was divorced with three children all under the age of 9 and with a good support system in place. The Veteran noted that he was working as a mailman but had been out of work since January 2012 due to back surgery; the Veteran stated that he attempted to return to work for a week but had been out of work for the past few weeks. The Veteran also indicated that he was a minister. The Veteran denied financial hardship but did admit things were “tight” since he was out of work. The Veteran denied immediate mental health problems and denied a history of mental health diagnoses. The Veteran denied suicidal and homicidal ideation, nor express any safety concerns or issues. The Veteran was afforded an April 2013 VA examination. The Veteran reported his early years were “rough” and experienced depression with a psychiatric hospitalization during his freshman year in high school; the Veteran also indicated attempting suicide twice. The Veteran described his current relationship as “complicated”, stating that he married in 2001 but during this marriage he began another relationship with his current partner for the past 11 years. The Veteran indicated he divorced his wife after his return from deployment. The Veteran stated that upon entering the military his social life expanded to include singing in public and at local night clubs, making him popular with his peers. The Veteran reported that he currently does limited activities and only travels between, work, home and church. The Veteran denied interacting with a regular group of friends or acquaintances or activities with his family. The Veteran reported after deployment he worked at a beef company and has worked as a letter carrier with the Post Office for the past 8 years. The Veteran stated that he initially found postal work difficult because of his ongoing divorce and singing in two bands at the time, noting that he had almost lost his job at one point where “he would sing until four in the morning and have to report for work at six.” The Veteran noted that after his divorce, he also discontinued singing with the bands. The Veteran reported being arrested in 2011 for driving on a suspended license, and that license had been suspended because of failure to appear for a speeding ticket. The Veteran denied other legal difficulties. The Veteran currently complains of easily being startled by loud noises and swerving on the road to avoid debris. The Veteran stated that he has not received any mental health treatment since he was a teenager. The Veteran reported sleeping 3 to 4 hours and stated that he “acts out” while sleeping without recalling specific dreams or nightmares. The Veteran acknowledged being irritable and his family has learned to be cautious around him. The examiner found the Veteran with symptoms of depressed mood, anxiety, suspiciousness and chronic sleep impairment. The Veteran was observed to be neatly and appropriately groomed in casual attire. The Veteran was alert, coherent and oriented. The Veteran’s mood and affect were found to be depressed with no disturbance in thought or memory function. The Veteran denied suicidal and homicidal ideation and impulses. In a June 2013 mental health consultation, the Veteran reported having considerable emotional upset and PTSD since his deployment. The Veteran reported while his family is small, they are close and supportive of one another. The Veteran noted he was married for 5 years while in active service but later divorced and was currently married again; the Veteran described his current relationship with his current wife as “very close and supportive.” The Veteran noted that he was struggling financially since he had to quit his job with the Postal Service and living on a single income. The Veteran stated that he has been on leave from his job since March 2013 due to back injury and surgery and “anticipates he will be disabled permanently as doctors are not very optimistic he’ll be able to return to his job as a mail carrier.” The Veteran denied any psychiatric history. The Veteran was observed to be neat, well groomed, and casually dressed. The Veteran was alert and oriented with grossly intact memory and thought process. The Veteran’s mood was reported to be “pretty depressed” with affect incongruent with mood. The Veteran denied hallucination, suicidal and homicidal ideation. The Veteran demonstrated appropriate judgement and insight. In a June 2013 Social Security Administration (SSA) disability evaluation, the Veteran stated that his depression had worsened with mood swings due to no quality of life; the Veteran stated that he spends all day staying in the house and sleeping on the sofa. In an August 2013 psychology note, the Veteran reported continued struggles with depression symptoms, back pain, and financial difficulties. The Veteran presented a letter written by his fiancé of 11 years that described his recent nightmares, irritability, social withdrawal, self-imposed isolation, and rapid mood swings. The Veteran was observed to be neat, well-groomed and casually dressed. The Veteran was alert and oriented with grossly intact memory and thought process. The Veteran’s mood was reported to be “depressed” with affect incongruent with mood. The Veteran denied hallucination, suicidal and homicidal ideation. The Veteran demonstrated appropriate judgement and insight. The treating provider also prepared a letter for the Veteran. The provider wrote that the Veteran reported feelings of emotional detachment; sleep disturbance; nightmares; irritability; anger; hypervigilance; exaggerated startle; mood swings; social withdrawal and isolation; flashbacks; intrusive memories; fear; and depression. The provider stated that the Veteran’s symptoms negatively impacted his ability to function and were indicative of moderate to severe impairment. In an October 2013 mental health note, the Veteran presented with symptoms of depression, more frequent and worse nightmares, moodiness, and irritability. The Veteran noted he was a mail man before back surgery and was currently applying for disability. The Veteran reported 4 kids “from multiple ladies” and current fiancé. The Veteran described an on and off relationship with his fiancé of 12.5 years and noted that he was recently engaged; however, the provider noted the Veteran also reported “married to mother of 10-year-old daughter for 4 years.” The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was “alright” with appropriate affect and coherent thought. The Veteran was alert and oriented with average intelligence, unimpaired judgment, and good memory. The Veteran denied hallucinations and feelings of hurting himself or others. In an October 2013 SSA report, the treating provider noted review of the record showed multiple medical contacts prior to June 2013 with no reports of anxiety or depression. The provider noted at the time of application for SSA the Veteran had begun seeing VA since December 2011 but denied immediate mental health problems or issues with attention, instruction or authority. The provider noted that review of the record between December 2011 to May 2013 the Veteran reported normal sleep and appetite. The Veteran submitted a November 2013 PTSD disability benefits questionnaire (DBQ). The Board notes the DBQ was performed by the provider who evaluated the Veteran in August 2013 and provided a letter. The Veteran reported a 12-year committed relationship with two kids and also providing child support for two other children. The Veteran stated that relationships outside of the immediate family are “distant due to past trust issues” but relationships with his family were close and supportive. The Veteran reported he was technically still employed with he US Postal Service but was currently on leave without pay due to back surgeries and increased functional impairment. The Veteran reported symptoms of emotional detachment; sleep disturbance; nightmares; irritability; anger; hypervigilance; exaggerated startle; mood swings; social withdrawal; flashbacks; intrusive memories; panic attacks; difficulty driving; and being fearful. The provider found symptoms of depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; flattened affect; disturbance of motivation and mood; difficulty establishing and maintaining effective relationships; and difficulty adapting to stressful circumstances. The provider indicated the Veteran’s symptoms resulted in total occupational and social impairment. In a separate November 2013 mental health note, the Veteran reported nightmares 4 to 5 times a week and wakes up every 2 hours. The Veteran was observed to be clean and appropriately dressed. The Veteran’s mood was “fine” with appropriate affect and logical thought. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, delusions, suicidal and homicidal ideation. In a January 2014 mental health note, the Veteran complained that he stilled did not sleep well with nightmares 3 to 4 times a week and “more and more I don’t like people behind me.” The Veteran stated that he was busy every day with house chores and children; the Veteran reported a “very good” relationship with his wife and that they were expecting another child this coming June. The Veteran was observed to be clean and appropriately dressed. The Veteran’s mood was “good” with appropriate affect and logical thought. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, delusions, suicidal and homicidal ideation. In a March 2014 psychology note the Veteran reported continued struggles with depression, PTSD, back pain, and financial difficulty. The Veteran noted his financial problems had worsened with their car repossessed, eviction, and struggles to keep a roof over their head with a baby due in June. The Veteran was observed to be clean and appropriately dressed. The Veteran’s mood was “living day to day, doing the best I can” with affect congruent with mood. The Veteran was alert and oriented with organized thought. The Veteran demonstrated appropriate insight and judgement. The Veteran denied hallucinations, delusions, suicidal and homicidal ideation. The Veteran was afforded a July 2014 VA examination. The Veteran reported living with his fiancé and their children and described a typical day consisted of preparing meals and sitting on the couch watching movies. The Veteran noted that he tries his best to interact with the children but is limited in physical activity due to back surgeries in April and September 2013; the Veteran indicated that his health insurance was cancelled and therefore unable to purchase his pain medication. The Veteran stated that he has not returned to work as a mail man since his back surgeries and his family are experiencing financial difficulties while living only on his fiancé’s income. The Veteran stated that he was ticked in December 2013 because his auto insurance had lapsed; the Veteran also indicated that his driver license was in danger of being suspended because his child support for his oldest daughter was in arrears. The Veteran report his current complaints are insomnia and exaggerated startled response. The Veteran also complained of impaired short-term memory where he has “left the stove on; forgotten to pick up his daughter up from school; and forgotten to pay a bill even though he had the money and intended to do so.” The examiner found the Veteran with symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; flattened affect; disturbances of motivation and mood; and difficulty adapting to stressful circumstances. The Veteran was observed to be alert, coherent, and oriented with good hygiene and grooming. The Veteran’s mood and affect were depressed; the Veteran spoke of “having a damaged sense of self-worth. The Veteran denied hallucinations, suicidal and homicidal ideation. The examiner found the Veteran’s symptoms resulted in occupation and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks during periods of significant stress; or symptoms controlled by medication. The examiner remarked the Veteran’s level of severity was determined to be moderate but found no evidence that the Veteran’s PTSD symptoms negatively impaired his ability to function in a work setting. The examiner noted the Veteran’s unemployment has had a great negative impact on his family’s finances and therefore resulted in significant emotional distress. In a separate July 2014 mental health note after the VA examination, the Veteran complained of being “irritated easily for no reason.” The Veteran reported feeling irritated for a couple months with no reason but did state that he could tell differences when he was on or off his medication. The Veteran reported nightly nightmares and an appetite that “comes and goes.” The Veteran report current stressors where he was taking care of a new baby girl and stressed when she cries; being stuck in the house when his wife takes the only car to work; a recent court appearance over child support with a possibility of jail time due to unpaid child support; and financial difficulty where he was awaiting more “VA service connection/Post Office disability/Social Security disability.” The Veteran was observed to ba clean and appropriately dressed. The Veteran’s mood was “okay” with anxious affect. The Veteran demonstrated good insight and judgment and logical thought process. The Veteran denied hallucinations, suicidal and homicidal ideation. In a January 2015 mental health note, the Veteran reported “doing alright” and stated that he was unable to make an October appointment because his car had broken down. The Veteran stated that his wife works, and he continues to stay home and take care of the baby and kids. The Veteran was observed to be clean and appropriately dressed. The Veteran’s mood was “fine” with anxious affect. The Veteran demonstrated good insight and judgment and logical thought process. The Veteran denied hallucinations, suicidal and homicidal ideation. In August 2015 the Veteran submitted a mental health medical statement prepared by the provider who performed the November 2013 PTSD DBQ. The provider stated the Veteran had symptoms of intrusive thoughts; nightmares; flashbacks; issues with sleep; arousal symptoms that impacted sleep, relationships and anger control; and avoidance symptoms leading to social withdrawal and memory suppression. The provider indicated the Veteran’s symptoms resulted in occupational and social impairment with deficiencies in most areas. In a September 2015 psychology note, the Veteran reported continued struggles with depression, anger, and significant severe PTSD symptoms. The Veteran stated that his financial difficulties had improved but was feeling “very guilty about being very difficult to live with.” The Veteran noted issues with anger, irritability, agitation, and depression that cause him to yell at his wife and kids and make them feel “they have to walk on eggshells.” The Veteran was observed to be neat, well-groomed and casually dressed. The Veteran’s reported his mood as “I’ve been very angry” with affect congruent with mood. The Veteran demonstrated appropriate insight and judgment, logical thought process and intact memory. The Veteran was observed to be alert and oriented. The Veteran denied hallucinations, suicidal and homicidal ideation. In a separate September 2015 mental health note, the Veteran reported that it has been stressful. The Veteran reported mood swings occurring twice a month lasting a week with irritability, anger, and depression. The Veteran stated that he has frequent nightmares relating to violence and his last depressive episode was one month ago. The Veteran stated his family life is about the same where he stays home, and his wife works; the Veteran noted his wife was supportive. The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was okay with appropriate affect. The Veteran was alert and oriented with logical thought. The Veteran demonstrated fair insight and judgement; average intelligence; and good memory. The Veteran denied hallucinations, suicidal and homicidal ideation. In a September 2015 decision review officer (DRO) hearing, the Veteran’s representative referred to the submitted August 2015 letter regarding the severity of his psychiatric symptoms. The representative also referred to the Veteran’s GAF scores to indicate the severity of the Veteran’s psychiatric disability; however as addressed above, the Board finds that GAF scores are no longer used in evaluating psychiatric disorders. The Veteran testified that his symptoms of PTSD was responsible for ending his first marriage and noted severe mood swings, issues with anger, and breaking things. The Veteran stated that he was an extrovert, “happy go lucky” prior to deployment but after his return he had a lot of trouble dealing with a lot of people and that loud noises immediately anger him. The Veteran testified that following his separation from service he went through eight jobs between 2004 and 2005, noting a “lack of initiative about anything” until “reality hit me…I have children to support.” The Veteran described his typical day consisted of taking care of his 15-month year old child and housekeeping. The Veteran stated that at his job at the Post Office he would argue with employees and somedays would not come in due to “periods of withdrawing…out on my route until 4:00, 5:00 in the afternoon…just doing nothing.” The Veteran attributed his job to his supervisor and that had he had a “normal supervisor”, he would have been fired a long time ago due to arguing with employees and lack of production. The Veteran stated that his current symptoms involve more nightmares, sleep issues and irritability where he “can’t stop it and I withdraw … a butthole to the tenth power and I just rather be alone and not deal with anything.” The Veteran stated that he cannot sit with his back to the door, unable to deal with large crowds, and swerves around debris in the road while driving because of reminder of improvised explosive devices. The Veteran state that when “I get to the point to where I feel like I’m about to…you know…thank God I haven’t gone to violence….it’s almost like rage and I have to get away”, the Veteran noted that he could go from 0 to 100 from one minute and then become fine the next. The Veteran also stated experiencing mood swings that last longer to two to three weeks at a time. In a November 2015 mental health note, the Veteran reported that he was doing alright. The Veteran reported prescribed medication helps with his nightmares, but he still had difficulty maintaining sleep. The Veteran stated that he was feeling pretty good and continues to stay home and take care of his 4 children. The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was good with appropriate affect. The Veteran was alert and oriented with logical thought. The Veteran demonstrated fair insight and judgement; average intelligence; and good memory. The Veteran denied hallucinations, suicidal and homicidal ideation. In a December 2015 mental health note, the Veteran complained that he still could not sleep even with prescribed medication. The Veteran reports that he often has combat-related dreams. The Veteran reported his mood is pretty good, increased appetite, and that the children are happy. The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was okay with appropriate affect. The Veteran was alert and oriented with logical thought. The Veteran demonstrated fair insight and judgement; average intelligence; and good memory. The Veteran denied hallucinations, suicidal and homicidal ideation. In a November 2016 mental health note, the Veteran complained that he could not sleep without medication. The Veteran stated that he felt depressed 6 months ago but now felt alright. The Veteran stated that he still stays home and takes care of the children. The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was okay with appropriate affect. The Veteran was alert and oriented with logical thought. The Veteran demonstrated fair insight and judgement; average intelligence; and good memory. The Veteran denied hallucinations, suicidal and homicidal ideation. In a June 2017 mental health note, the Veteran stated that sleeping was still a problem and continued to experience hypervigilance, increased startled response, periods of irritability, and avoidance of crowds. The Veteran stated that he has been married for 15 years and he stays at home much of the time to take care of the children. The Veteran stated that driving alone in the car was stress reducing and he would visit a good friend who is an R&B artist. The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was stable with appropriate affect. The Veteran was alert and oriented with logical thought. The Veteran demonstrated fair to good insight and judgement and sound intelligence. The Veteran denied hallucinations, suicidal and homicidal ideation. In a September 2017 mental health note, the Veteran reported he was sleeping better with medication but was very irritable. The Veteran described his irritability as significant with strong isolation tendencies and continued to experience hypervigilance and increased startle response. The Veteran reported the same family situation. The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was noted to be with “some depression, relatively tense, preoccupied, and stable” with appropriate affect. The Veteran was alert and oriented with logical thought. The Veteran demonstrated fair to good insight and judgement and sound intelligence. The Veteran denied hallucinations, suicidal and homicidal ideation. In a March 2018 mental health note, the Veteran reported that he was “pretty miserable, discontent, not satisfied with anything, irritable mentally and emotionally tired.” The Veteran discussed marital issues and general life stressors to include chronic pain, broken sleep, and conflict-like dreams. The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was angry, tense and irritable with mildly labile and mostly restricted affect. The Veteran was alert and oriented with logical thought. The Veteran demonstrated fair to good insight and judgement, average intelligence and good memory. The Veteran denied hallucinations, suicidal and homicidal ideation. In a May 2018 mental health note, the Veteran stated that he was “not my normal self, the way I react to my environment, can go the whole day without talking, in my own world.” The Veteran reported persistent and intrusive thoughts, active avoidance of symbolic reminders of traumatic military experiences, and marked reactivity to cures. The Veteran noted having fragmented sleep, emotional numbness and detachment; the Veteran described feeling “emotionally, mentally tired” and was demoralized by a painful loss of mobility despite surgery and medication. The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was angry, tense and irritable with normal range of expression in affect. The Veteran was alert and oriented. The Veteran was found with obsessive thought pattern but with no delusional thoughts, ideas of reference or grandiosity. The Veteran demonstrated fair to good insight and judgement, average intelligence, and good memory. The Veteran denied hallucinations, suicidal and homicidal ideation. In a November 2018 mental health note, the Veteran complained of “mood swings that are hard to understand and frustrating; triggers where sometimes hit these walls where I don’t to be bothered by anything…mind constantly running.” The treating provided noted the Veteran’s mood tended to vacillate, had anxious overeating, and would be “angry for no reason at time.” The Veteran reported marital separation but planned for reconciliation and enjoys time with his child. The Veteran was observed to be appropriately dressed and groomed. The Veteran’s mood was angry, tense and anxious at times with normal range of expression in affect. The Veteran was alert and oriented. The Veteran was found with obsessive thought pattern but with no delusional thoughts, ideas of reference or grandiosity. The Veteran demonstrated fair to good insight and judgement, average intelligence, some difficulty with retention of recent memory but good remote memory. The Veteran denied hallucinations, suicidal and homicidal ideation. At the Veteran’s May 2019 hearing, the Veteran testified that following his separation from service, the Veteran was “unconcerned …. Did a lot of partying, a lot of drinking, a lot of women, a lot of pill popping, ended up getting a divorce at the time … a lot of self-destructive things.” The Veteran stated that he applied at the post office and took a year or so to get into work, beginning in March 2005 and working there until 2012 to 2013. The Veteran stated that he did not receive any mental health treatment during this time because “I was totally disenfranchised from the military, I had a lot of anger, a lot of different stuff going on that I really didn’t understand…nothing as far like a self-help or self-anything.” The Veteran stated that he did not care about anything other than having a good time; the Veteran stated that a lot of relationships were damaged at the time because “I didn’t feel anything, I didn’t care about anything.” The Veteran stated that when he underwent surgery in 2012, he became immobile and while staying home with his wife who he had been together with since 2002 “pushed and pushed, actually drove me for the first time [to VAMC]” to receive mental health treatment. The Veteran testified that he was previously outgoing but now he was isolated because of getting irritated and frustrated. The Veteran stated that he would rather not death with people and that this has affected his life as a whole; the Veteran stated that he “missed out on so much because I can’t and I don’t’ deal with a lot of people.” The Veteran stated he had issues with his family but did not provide specific detail. The Veteran stated that sleep came at a premium and it was often broken. The Veteran stated that he would experience anxiety or panic attacks while driving due to encounters with improvised explosive devices while in service; the Veteran stated that he subconsciously swerves while driving because of this. The Veteran stated that he is always irritable and noted while waiting for the hearing “I was pissed because I had to come this morning…just leaving home stresses me so I would rather just stay at home.” In a submitted April 2019 statement from the Veteran’s wife, the Veteran’s wife stated that when she first met the Veteran, he was a funny, outgoing, charismatic and charming guy who was the life of the party wherever he went. The Veteran’s wife stated that after his return from service he changed where he “no longer cared…lived reckless…it was like he did not have or feel emotions.” The Veteran’s wife stated that in 2012 things became worse as the Veteran became angry over small things, yell and slam things, and be angry for days. The Veteran was observed to go for days with only 3 to 4 hours of sleep at a time and would be woken up because of nightmares which cause him to become more distant, irritated, anxious, distracted and hypervigilant. The Veteran’s wife stated that they no longer go out because the Veteran experienced anxiety looking at people and checking his surroundings to the point that he became physically sick. The Veteran was noted to only do online shopping and unable to be in crowds. The Veteran while driving panics whenever he sees anything in the road and swerves to avoid the object. The Veteran’s wife stated that her and kids hated going home and “never knew what [Veteran] would they be coming home to.” The Veteran’s wife stated that they were afraid to make too much noise, say the wrong thing or do anything that would cause the Veteran to “explode or become distant. The wife also stated there would be times the Veteran would go for days or weeks without interacting or speaking to his family. The Veteran’s wife also stated that the Veteran’s memory loss became bad where the Veteran would forget periods of time, conversations, where he put things, and the names and faces of people he talked to. The Veteran was afforded a December 2020 VA examination. The Veteran reported being married to his second wife for 6 years with three children. The Veteran noted being married to his first wife for 4 years with one child; the Veteran initial denied paying child support but later stated that his SSA disability pays for child support. The Veteran stated that following separation from the military he worked temporary jobs for 1 year before becoming a letter carrier for the US Postal Office for 10 years until 2015 where he stated that he was medically retired due to lumbar back problems. The examiner found the Veteran with symptoms of depressed mood; anxiety; disturbances of motivation and mood; and difficulty in adapting to stressful circumstances. The Veteran was observed to be casually dressed and well-groomed. The Veteran’s mood was euthymic with stable and congruent affect. The Veteran’s demonstrated adequate insight and judgement with linear thought. The Veteran showed no signs or symptoms of delusions or hallucinations and denied suicidal ideation and homicidal ideation. The examiner remarked their belief that the Veteran should not be considered at a current or imminent risk. The examiner found the Veteran’s symptoms to result in occupational and social impairment with reduced reliability and productivity. The Board finds that after review of the evidence of record above, the Board does not find that the Veteran’s symptoms of his service-connected PTSD are enough to warrant a 100 percent rating. As noted above, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The Board finds the preponderance of evidence does not show Veteran does not manifest or nearly manifest the behavioral elements of 100 percent disability. There is no documented instance of grossly inappropriate behavior. There is no evidence of intermittent ability to perform activities of daily living to include maintaining minimal personal hygiene. There is no consistent documentation during this period to show the Veteran being an imminent danger to himself or others, let alone persistence of such danger. Although the provider in the November 2013 PTSD DBQ found the Veteran with total occupation and social impairment, the provider did not provide specific details or findings in the criteria to support this finding; the same provider in August 2015 would find the Veteran’s symptoms only resulted in impairment in most areas instead of total impairment. There is no clinical evidence of actual disorientation to time and place. The evidence does not show persistent delusions or hallucinations. Although the Veteran in the treatment record at times was found with some issues with memory recall, the examinations of record did not find any reported symptoms of memory loss to rise to the level of forgetting the names of close relatives, occupation or of his own name and later examinations found the Veteran’s memory to be intact. The Board has considered the submitted statements from the Veteran and his wife regarding the severity of the Veteran’s PTSD. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the evidence of record as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions are outweighed by the evidence of record. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). As such, based on the totality of the disability picture, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s PTSD symptoms is manifested by an evaluation in excess of 70 percent. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Total Disability Rating Based on Individual Unemployability (TDIU) VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded from obtaining or maintaining any substantially gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. § § 3.340, 3.341, 4.16. Total disability ratings 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, provided that the Veteran meets the schedular requirements. 38 C.F.R. § 3.340. Specifically, 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 that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § § 3.340, 3.341, 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following disabilities will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16 (a). The 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). In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. § § 3.341, 4.16, 4.19. “Substantially gainful employment” is that employment “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). “Marginal employment shall not be considered substantially gainful employment.” 38 C.F.R. § 4.16 (a). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough; the ultimate question 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 (1993). Alternatively, if a veteran is found to be unemployable because of service-connected disabilities but does not meet the percentage standards set forth in 38 C.F.R. § 4.16 (a), the rating authority should refer the matter to the Director of the Compensation and Pension Service for extraschedular TDIU consideration. 38 C.F.R. § 4.16 (b) (2018). The veteran is not required to show 100 percent unemployability; the question is whether he or she is unable to pursue a substantially gainful occupation. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). Whether the veteran can actually find employment is not determinative, as the focus of the inquiry is on “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) (emphasis in original). The Board cannot consider entitlement to TDIU on an extraschedular basis in the first instance, but it is required to ensure that all cases where there is evidence of unemployability due to service-connected conditions are referred to the Director for initial consideration under 38 C.F.R. § 4.16 (b). See Bowling v. Principi, 15 Vet. App. 1 (2001). The ultimate responsibility for a TDIU determination is a factual rather than a medical question and is an adjudicative determination made by the Board or the AOJ. Geib, 733 F.3d at 1354 (citing 38 C.F.R. § 4.16 (a)). The Veteran is currently service connected for PTSD evaluated at 70 percent effective from June 13, 2012; right hip muscle strain (abduction) evaluated at 20 percent effective from June 13, 2012; right hip condition (extension) evaluated at 10 percent effective from June 13, 2012; tinnitus evaluated at 10 percent effective from June 13, 2012; and right hip muscle strain (flexion) evaluated as noncompensable. The Veteran’s combined rating was 80 percent from June 13, 2012. As such, the Veteran meets the threshold schedular requirement for TDIU. 38 C.F.R. § 4.16(a). The Board notes the Veteran has been granted TDIU effective from September 1, 2014; therefore the Board will evaluate whether the Veteran is entitled to TDIU prior to this date. In June 2012 the Veteran reported working as a mail man but had not worked since January 2012 due to back surgery. The Veteran stated that he attempted to return to work for a week but has not worked for the past few weeks. The Veteran also indicated that he was a minister. In an April 2013 VA examination for mental disorders, the Veteran stated that he worked for the US Post Office since March 2005 and had encountered initial difficulties because of pending divorce and singing in two bands that would go late and he would need to work a few hours later, almost costing him his job at one point. In June 2013 the Veteran reported that he currently worked for the US Post Office and his duties required him to carry weights up to 75 pounds. In a June 2013 SSA application, the Veteran noted that after his separation from service as a clerk and then mail carrier for the US Post-Office from July 2004 until the present. In a July 2013 reconsideration, the Veteran reported he was currently not work due to his spine problem and was absent 3 to 6 months in the previous year. In a separate June 2013 record, the Veteran reported that he has been on leave from his job with the US Postal Service since March 2013 because of his back injury and anticipated that he would be disabled permanently because his doctors were not optimistic that the Veteran would be able to return to his job as a mail man. The Veteran noted that he had filed for SSA disability and VA compensation. In an October 2013 SSA evaluation, the evaluator noted the Veteran had multiple medical contacts prior to June 2013 with no reported anxiety or depression and continued work until March 2013 when the Veteran stopped due to physical issues. The evaluator found the Veteran had no psychiatric limitations and no problems with attention, instruction, or authority. In the November 2013 PTSD DBQ, the treating provider noted the Veteran reported that he was still technically employed but on unpaid leave due to back surgeries and increased functional impairment. The provider found symptoms to include of difficulty or inability to adapt to stressful circumstances and establishing or maintaining relationships. The provider found the Veteran’s psychiatric disability to result in total impairment. In a July 2014 VA examination for mental disorders, the Veteran reported that he had not returned to work as a mail man since his back surgery. The Veteran reported impaired short-term memory where he has forgotten to pick up his daughter from school; leave the stove on; or forget to pay the bill. The examiner found the Veteran’s symptoms resulted in occupation and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks during periods of significant stress; or symptoms controlled by medication. The examiner remarked the Veteran’s level of severity was determined to be moderate but found no evidence that the Veteran’s PTSD symptoms negatively impaired his ability to function in a work setting. The examiner noted the Veteran’s unemployment has had a great negative impact on his family’s finances and therefore resulted in significant emotional distress. In a July 2015 SSA decision, the Administrative Law Judge (ALJ) found the Veteran had not engaged in substantial gainful activity since March 27, 2013, the alleged onset date. The ALJ found the Veteran with sever impairments to include anxiety, depression, PTSD, and multiple lumbar spine disc surgeries. The Judge noted the Veteran’s mental disorder resulted in marked restriction in activities of daily living; moderate difficulties in maintaining social function; moderate difficulty in maintaining concentration, persistence or pace; and one to two episodes of decompensation of extended period. The ALJ found the Veteran with residual functional capacity to perform sedentary work but noted the Veteran’s emotional impairment prevented him from performing substantial gainful activity requirements in memory, production, pace, interaction, and attendance requirements. The ALJ found the Veteran would be unable to perform any past relevant work and his acquired job skills did not transfer to other occupations with adequate residual functional capacity. SSA decisions are not controlling but are pertinent to determining a veteran’s ability to engage in substantially gainful employment. Martin v. Brown, 4 Vet. App. 136 (1993); Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992). In this case, the findings of the ALJ are consistent with the record and the lay and medical evidence of the functional limitations resulting from the Veteran’s service-connected disabilities, as well as his level of education and previous work experience. In an August 2015 mental health statement, the treating provider stated the Veteran had symptoms of intrusive thoughts; nightmares; flashbacks; issues with sleep; arousal symptoms that impacted sleep, relationships and anger control; and avoidance symptoms leading to social withdrawal and memory suppression. The provider indicated the Veteran’s symptoms resulted in occupational and social impairment with deficiencies in most areas such as interpersonal relations, judgement, impulse control, concentration, and memory. The provider further indicated that the Veteran’s PTSD prevented him from being able to work. At the September 2015 DRO hearing, the Veteran testified that following his separation from service he went through several jobs in succession that did not last a month because “my attitude was just horrible.” The Veteran stated that he went through about eight jobs between 2004 to 2005. The Veteran stated that it was not until he began his job at the US Post Office that he was able to work consistently. The Veteran stated that he would argue with other employees and his supervisor would sometimes need to “convince me to come in…when I’m going through my periods of withdrawing…out on my route until 4:00…5:00 in the afternoon…just doing nothing.” The Veteran noted that he had a wonderful supervisor who “let me get away with a lot more than I’d probably should have in the way of my absence” and admitted that “I shouldn’t had that job for as long as I did” and his supervisor was the main reason why he was able to keep that job. The Veteran indicated that if he had a “normal supervisor” he would have been fired a long time ago due to arguing, tardiness, and lack of production. Review of the medical treatment record shows the Veteran reported that he continued to stay at home and take care of the children. At the Veteran’s May 2019 hearing, the Veteran’s representative indicated that the Veteran was seeking TDIU from March 2013, the date that he stopped working. The Veteran indicated that he worked at the Post Office from March 2005 until 2013. The Veteran noted that in the years leading up to 2013 he was often late to work or would not come in at all and that his work was subpar at best; the Veteran stated that if not for his supervisors he would not have a job at that point. At the Veteran’s December 2020 VA examination for mental disorders, the Veteran reported working a temporary job for 1 year and then as a letter carrier for the US Post Office for 10 years until 2015 when he was medically retired due to lumbar back problems. The Veteran stated he began receiving Social Security disability income starting in 2013. The Board finds that resolving all reasonable doubt in favor of the Veteran, that TDIU is warranted for the Veteran’s service-connected disabilities from March 27, 2013 to September 1, 2014. In addition to meeting the schedular criteria for TDIU, the record shows evidence that the Veteran’s symptoms of his service-connected disabilities to include PTSD during this period markedly interfere with his ability to obtain and maintain gainful employment. Considering the record of the Veteran’s symptoms and impairments from his service-connected disabilities to include findings from VA examinations and testimony, the Board finds that that entitlement to TDIU from March 27, 2013 to September 1, 2014, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. The evidence of record to include VA examinations shows the Veteran’s complaints and symptoms characterized by irritability; anxiety; difficulty adjusting to stressful circumstances; and inability to establish and maintain effective social and work relationships attributable to his service-connected disabilities. The Board notes that these symptoms severely limit the Veteran’s options for employment as his symptoms, for example, restrict him from undertaking work that involves working with other people or dealing with the public, due to his inability to establish and maintain effective relationships. The Board notes the Veteran’s previous work history as a letter carrier involved activities that the evidence currently shows the Veteran is either unable to or will have difficulty performing these duties. A July 2015 SSA decision found the Veteran disabled from March 27, 2013 and unable to perform substantial gainful activity related to his past work due to impairments to include psychiatric symptoms from his PTSD and an August 2015 medical letter opined the Veteran’s PTSD symptoms prevented the Veteran from obtaining and maintaining gainful employment. Furthermore, he has not worked for many years since 2013. Although the VA examiner opinions did not specifically state the Veteran was unemployable, they did note that the Veteran’s symptoms of his service-connected disabilities did or would impact any occupational work involving such activities, either limiting or opining the Veteran would be unable to work that required these motions relating to his symptoms. Moreover, the “applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner.” Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Considering the SSA determination of the Veteran to be disabled based their findings on the Veteran’s service-connected disabilities to include PTSD; the August 2015 letters of the Veteran’s inability to gain and sustain gainful employment; and record of the Veteran’s symptoms and impairments from his service-connected disabilities, the Board finds that entitlement to TDIU from March 27, 2013 to September 1, 2014, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.