Citation Nr: 21026859 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 98-06 296 DATE: May 4, 2021 ORDER Entitlement to an initial 70 percent rating, but no higher, for posttraumatic stress disorder (PTSD) with major depressive disorder (MDD) and psychotic features for the appeal period prior to May 6, 2020, is granted. Entitlement to an initial rating in excess of 70 percent for PTSD with MDD and psychotic features from May 6, 2020, is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU) from September 24, 1998, to October 9, 2019, is granted. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's service-connected PTSD with MDD and psychotic features is most appropriately characterized as occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood. 2. For the appeal period prior to October 10, 2019, the Veteran's service-connected PTSD with MDD and psychotic features precluded him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, the criteria for entitlement to an initial 70 percent rating, but no higher, for PTSD with MDD and psychotic features for the appeal period prior to May 6, 2020, have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for entitlement to a rating in excess of 70 percent for PTSD with MDD and psychotic features have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, DC 9411. 3. Resolving all reasonable doubt in favor of the Veteran, the criteria for the award of TDIU from September 24, 1998, to October 9, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1973 to August 1976 and in the Air Force National Guard from April 1983 to July 1983 and from March 1984 to August 1987. At the outset, the Board of Veterans' Appeals (Board) acknowledges that this appeal has a long and complicated procedural history. These matters come before the Board on appeal from a February 1999 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which denied, in pertinent part, the Veteran's claims of service connection for an acquired psychiatric disability, to include PTSD (which was characterized as major depression (claimed as schizophrenia)) and entitlement to a TDIU. The Veteran appealed this decision and, in September 2000, testified at a Board hearing before a Veterans Law Judge (VLJ). A transcript of that hearing is associated with the claims file. The Board notes that the VLJ who held the September 2000 hearing is no longer a member of the Board and, as such, in August 2015, VA informed the Veteran that he had the right to a new hearing before a VLJ who would participate in the decision. The Veteran subsequently declined another Board hearing. See August 2015 Correspondence. In December 2000, the Board denied the Veterans claims, to include entitlement to service connection for an acquired psychiatric disorder and entitlement to a TDIU. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In May 2001, the Court granted a Joint Motion for Remand (JMR), which vacated and remanded the December 2000 Board decision. In January 2002, June 2009, and July 2012 decisions, the Board remanded the Veteran's claims. Thereafter, in a July 2014 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for PTSD with MDD and psychotic features and assigned a 50 percent rating from February 5, 2005. The Veteran appealed this decision and in December 2015, the Board remanded the Veteran's initial increased rating claim for PTSD with MDD and psychotic features as well as his TDIU claim to the AOJ for additional development. In a May 2017 rating decision, the AOJ granted an initial 50 percent rating for the Veteran's PTSD with MDD and psychotic features from September 24, 1998. As this was not the maximum rating available for his disability, the claim remained in appellate status. Subsequently, in a May 2018 decision, the Board denied entitlement to an initial rating in excess of 50 percent for PTSD with MDD and psychotic symptoms and remanded his TDIU claim. The Veteran appealed the May 2018 Board decision to the Court and in February 2019, the Court granted a Joint Motion for Partial Remand (JMPR), which vacated and remanded the May 2018 Board decision in so far as it denied entitlement to an initial rating in excess of 50 percent for PTSD with MDD and psychotic features. In a November 2019 decision, the Board again denied entitlement to a rating in excess of 50 percent for PTSD with MDD and psychotic features and the Veteran again appealed that decision to the Court. While the Veteran's appeal was pending, in a May 2020 rating decision, the AOJ awarded a 70 percent rating for the Veteran's PTSD with MDD and psychotic features from May 6, 2020, the date of the Veteran's PTSD examination in connection with his TDIU claim. Thereafter, in November 2020, the Court granted a JMR that vacated and remanded the November 2019 Board decision. The parties (the Veteran and the Secretary of VA) agreed that in its November 2019 decision, the Board erred by not providing an adequate statement of reasons or bases for its decision and failed to adequately discuss relevant evidence of record. The Board notes that in April 2021, the Veteran filed a Decision Review Request: Higher-Level Review (VA Form 20-0996) that included the issue of entitlement to an increased rating for PTSD with MDD and psychotic features. However, the Veteran's initial increased rating claim for PTSD with MDD and psychotic features remains in the legacy system as part of the Veteran's original appeal. The evidence does not indicate that the Veteran withdrew this issue from the legacy appeal process or properly opted-in to the new claims and appeal process under the Appeals Modernization Act (AMA) for his original claim. Therefore, entitlement to an initial increased rating for PTSD with MDD and psychotic features remains before the Board in this legacy decision. Additionally, although the AOJ awarded a 70 percent rating for the Veteran's PTSD with MDD and psychotic features from May 6, 2020, the grant of an increased rating during the course of an appeal does not affect the pendency of that appeal. AB v. Brown, 6 Vet. App. 35 (1993). As the Veteran is presumed to be seeking the maximum allowable benefit and the maximum benefit has not yet been awarded, the claim is still in controversy and on appeal. Id The Board also notes that the Veteran has submitted several formal TDIU claims and that in January 2019, following the May 2018 Board remand, the Veteran submitted a Rapid Appeals Modernization (RAMP) opt-in form, requesting that his formal claims for entitlement to service connection for obstructive sleep apnea and for TDIU be adjudicated under the AMA. These claims were accepted into the AMA process. However, after a review of the Veteran's claims file, the Board finds that while the Veteran's formal TDIU claim is being processed under the AMA, a TDIU claim was already part and parcel of his legacy initial increased rating claim for PTSD with MDD and psychotic features pursuant to Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (the issue of entitlement to TDIU takes its place as part of an increased rating claim where a claimant or the evidence reasonably raises the possibility that the relevant disability causes or contributes to a claimant's unemployability). Considering the Board's duty to review the historical records, the Board finds that a Rice TDIU claim has been reasonably raised as part of his increased rating claim for PTSD, which is separate from his formal TDIU claim in the AMA system. See also Harper v. Wilkie, 30 Vet. App. 356 (2018) (when TDIU is part of an underlying claim for an increased rating, then a subsequent grant of TDIU that is not effective for the entire appeal period does not remove the TDIU issue from the appeal, and the Board should consider whether any earlier effective date is warranted). 1. Entitlement to an initial rating of 70 percent, but no higher, for PTSD with MDD and psychotic features for the period prior to May 6, 2020, and entitlement to an initial rating in excess of 70 percent thereafter The Veteran contends that he is entitled to initial increased ratings for his service-connected PTSD with MDD and psychotic features. Specifically, in a March 2021 brief, the Veteran's representative argued that he was entitled to a 70 percent rating for the entire appeal period as his symptoms more closely approximated those contemplated under the 70 percent rating. As discussed above, because the Veteran's increased rating claims stem from his original service connection claim, the Board will consider whether the Veteran is entitled to an increased rating for his PTSD with MDD and psychotic features from September 24, 1998. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4 (2018). The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Evaluations for psychiatric disabilities are assigned pursuant to VA's General Rating Formula for Mental Disorders under 38 C.F.R. § 4.130. The Veteran's PTSD is rated under DC 9411. See 38 C.F.R. § 4.130. Under DC 9411, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more often than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating contemplates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 100 percent disability rating is warranted for a psychiatric disorder resulting in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Board notes that considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Further, rating evaluations under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). Although a veteran's symptomatology is the primary consideration in assessing their disability rating based on a mental disorder, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in "most areas" for that rating. Id.; 38 C.F.R. § 4.13. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In the present case, after resolving reasonable doubt in the Veteran's favor, the Board finds that the frequency, severity, and duration of the Veteran's service-connected psychiatric disability symptoms most closely approximate those required for a 70 percent rating, but no higher, for the entire appeal period. In particular, the medical and lay evidence of record collectively indicates that the Veteran's psychiatric pathology for the entire appeal period has been productive of symptoms resulting in occupational and social impairment with deficiencies in most areas as to warrant a rating of 70 percent but do not reflect total occupational and social impairment so as to warrant a rating of 100 percent. The Board notes that "deficiencies" is not defined in the rating criteria, but the common definition of deficient is "lacking an essential quality or element." Webster's II New College Dictionary (3rd ed. 2005). For the entire appeal period, the medical evidence of record shows that the Veteran's psychiatric disability has resulted in social isolation and avoidance. For example, a May 2001 VA psychiatry treatment record reflects that the Veteran was very uncomfortable around gatherings of people, was inclined to experience panic attacks in unfamiliar situations, and that at that time, he was emotionally unable to cope with the responsibilities of jury duty. A June 2003 VA psychiatry record indicates that although the Veteran's medication had helped him feel less panicky around people, he still preferred to be alone and had a fear of going outside. Likewise, an April 2007 VA treatment record reflects that the Veteran reported that he gets paranoid around people, avoids going out, and was mostly a loner while the July 2007 VA examination reflects that the Veteran tended to isolate himself frequently and that his behavior was inappropriate from time to time. During the October 2011 VA examination, the Veteran also reported that he did not socialize with others outside of his family. The September 2012 VA examiner also found that the Veteran did not socialize and spent almost all of his time at home where he took care of minor chores. An October 2014 VA treatment record further reflects that the Veteran got excessively anxious when others came to his house and at times had panic type reactions with shortness of breath. This evidence shows that the Veteran's psychiatric symptoms manifested in symptoms that substantially affected his relationships and ability to socialize with others. The evidence also reflects that the Veteran's PTSD with MDD and psychotic features manifested in symptoms that substantially impaired occupational functioning. Specifically, an October 1998 State of Alabama work requirement form, signed by a psychologist, reflects that the Veteran was depressed, hospitalized the last time that he worked, and was not mentally and physically able to work. An October 1998 SSA assessment from a clinical psychologist also reflects that the Veteran often had deficiencies of concentration and that he was moderately limited in his ability to work in coordination with or proximity to others without being distracted by them. As such, the psychologist found that the Veteran should not work in a job where contact with the public was a basic job requirement and recommended a work environment where the Veteran would have infrequent interaction with coworkers in a spaced work setting due to his mood and personality factors. The Veteran also submitted a Temporary or Permanent Total Disability Certification, signed in December 1998 by a physician, certifying that the Veteran had a permanent psychiatric disability rendering him unable to work and earn money. The medical providers and medical treatment records further reflect occupational limitations related to the Veteran's PTSD with MDD and psychotic features. For example, during the March 2003 VA examination, the Veteran reported that he could not work because he usually hears voices on and off. The July 2007 VA examiner found that the Veteran had severe impairment in social and industrial adaptability due to his psychiatric disorders but was able to do his activities of daily living. Although the October 2011 VA examiner opined that the Veteran was capable of gainful employment, the examiner noted that he would work best in a low social environment with casual and infrequent social interactions as well as in a moderate stress environment with moderate levels of task variability. The October 2011 VA examiner further noted that the Veteran's mental health symptoms affect, but do not preclude, the ability to interact socially. On the other hand, the August 2019 private psychologist found that he Veteran's disability precluded substantially gainful employment. The private psychologist detailed the Veteran's symptoms, which included difficulty adapting to stressful circumstances, including work or a work like setting, and explained that the Veteran's near-continuous depression affected his ability to function independently, appropriately, or effectively. The private psychologist also opined that the Veteran exhibited occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood due to his PTSD, and that the Veteran had exhibited these deficiencies throughout the appeal period. Likewise, the May 2020 VA PTSD examiner found that the Veteran had occupational and social impairment with deficiencies in most areas and detailed, in particular, that the Veteran's PTSD impaired his ability to handle stress, to trust anyone, to respond positively to criticism, and to adapt to change. The VA examiner noted that the Veteran had difficulty remembering verbal instructions, organizing and prioritizing tasks, learning new software programs/platforms, multitasking, and making friends or positive relationships at work. The VA examiner also found that the Veteran's MDD made it difficult for him to sustain concentration to complete assigned tasks and that absenteeism, generally, is increased by MDD. This evidence collectively suggests that that Veteran's PTSD with MDD and psychotic features manifested in severe occupational impairments, including difficulty in adapting to stressful circumstances, which is a symptom contemplated under the 70 percent rating criteria. The medical evidence of record also indicates that the Veteran experienced suicidal ideation, which is also a symptom specifically contemplated by the 70 percent rating. The Board notes that although there are several instances where the Veteran denied suicidal ideations, he also reported suicidal ideations at various points during the appeal period. In this regard, in October 1998, the Veteran was hospitalized for an overdose and upon hospital arrival expressed suicidal thoughts. See October 1998 medical treatment records. During the June 1999 VA general medical examination, the Veteran reported that his depression was so bad at times that he just did not know how he was going to make it and expressed concerns about hopelessness. The September 1999 VA mental disorders examination additionally reflects that the Veteran had suicidal or homicidal ideations and that he had three serious suicide attempts, with the last one in 1998 when he was hospitalized. February 2000 and September 2000 VA treatment records also reflect suicidal thoughts. During the March 2003 VA examination, the Veteran denied suicidal or homicidal plans but had some ideas of reference. He was not considered suicidal or assaultive. An April 2008 VA psychiatry treatment record further reflects the Veteran's report that suicidal thoughts come and go but that he does not act on them. He was assessed as unstable. June 2010 and January 2015 VA psychiatry treatment records reflect that the Veteran felt hopeless. In a December 2019 statement from the Veteran, he reported that he still has occasional thoughts of suicide but no plan. During the May 2020 VA examination, the Veteran reported that he was very close to suicide. The examiner found that the Veteran should be considered an increased but not current imminent risk. The evidence also shows the Veteran's service-connected psychiatric disability manifested in hallucinations. In this regard, the Veteran has frequently reported to medical providers that he has experienced auditory hallucinations. See June 1999 VA general medical examination (reporting that he hears voices all the time); September 2000 Board hearing (testifying that he hears voices and feels like somebody is trying to kill him); May 2001 VA psychiatry note (reflecting the Veteran has occasional visual hallucinations); June 2002 VA treatment record (reporting that he is hearing unreal things); February 2003 VA psychiatry note (reporting hearing unreal voices); March 2003 VA mental disorders examination (reflecting that the Veteran was hearing voices, to include voices of his deceased mother and that he felt people are out to hurt him or kill him); September 2003 VA psychiatry note (reflecting that the Veteran reported hearing voices daily); June 2003 VA treatment record (reflecting that the Veteran still hears voices but this is less frequent); October 2004 VA psychiatry treatment record (reflecting that the Veteran occasionally has auditory hallucinations); February 2005 VA treatment record (reporting that he is hearing people talking to him); June 2005 VA psychosocial assessment (reporting last auditory hallucination was about two days ago); November 2005 VA treatment record (reflecting he has hallucinations); July 2006 VA psychiatry note (reflecting the Veteran has infrequent auditory hallucinations); July 2007 VA examination (reflecting the Veteran's report of auditory hallucinations and paranoid delusions every now and then); July 2010 VA treatment record (reflecting that the voices are occasional); May 2011 VA psychiatry note (reflecting occasional hallucinations or delusions); October 2011 VA examination (finding that the Veteran demonstrated delusions of the mild persecutory type); September 2012 VA examination (reflecting that the Veteran's depression is at times severe during which times he also has auditory and visual hallucinations); July 2017 VA examination (finding that visual hallucinations were initially caused by or a result of cocaine abuse). The medical evidence also indicates that the Veteran's psychiatric disability affects his memory and concentration. For example, the September 1999 VA mental disorders examination reflets that the Veteran's memory is impaired and that he is not reliable. Moreover, an April 2008 VA treatment psychiatry record reflects that it is hard for the Veteran to stay focused while the July 2017 and May 2020 VA examinations found that the Veteran also had problems with concentrating. Additionally, the evidence suggests that the Veteran experiences hypervigilance. For example, the July 2017 VA examination reflects that the Veteran reported that he is constantly on guard in his home, always thinking someone is out to get him or kill him, and that he is constantly checking windows and doors. The August 2019 private psychologist also found that the Veteran reported a longstanding history of obsessional rituals, such as continuously checking doors and windows throughout the night to the extent that it interfered with his ability to sleep. Likewise, in a December 2019 statement, the Veteran reported that he is constantly checking the doors and locks. This evidence suggests, to some extent, that the Veteran's PTSD with MDD and psychotic features manifests in obsessional rituals which interfere with his routine activities as contemplated by the 70 percent rating. Finally, the medical evidence of record also indicates that the Veteran's psychiatric symptoms include chronic sleep impairment, anger, depression, anxiety, paranoia, disturbances of motivation and mood, nightmares, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. See e.g., February 2005 VA treatment record (reflecting that the Veteran admitted to having poor anger control); August 2011 VA mental disorders examination (also reflecting symptom of impaired impulse control such as unprovoked irritability with periods of violence); September 2012 VA examination; July 2017 VA examination; and May 2020 VA examination. The Board acknowledges that for this period of time, the Veteran's psychiatric symptoms do not mirror all the symptoms enumerated for a 70 percent rating under the General Rating Formula for Mental Disorders and that there is evidence of record reflecting more moderate symptomatology at certain periods of time. However, affording the Veteran the benefit of the doubt, the Board finds that such evidence is reflective of the Veteran's waxing and waning psychiatric symptomatology and, thus, does reflect sustained improvement. Moreover, it is apparent that the Veteran's symptoms, especially his social isolation, hallucinations, anxiety, avoidance, suicidal ideations, and paranoia have been of the frequency, severity, and duration to have rendered the Veteran more nearly socially and occupationally impaired with deficiencies in most areas for the entire appeal period. See Mauerhan, 16 Vet. App. at 443; Vazquez-Claudio, 713 F.3d at 117. The Board does not, however, find, that the criteria for a 100 percent rating is warranted, to include from May 6, 2020, as the preponderance of the evidence does not indicate the Veteran's symptoms more nearly approximated total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; persistent danger of hurting self or others; grossly inappropriate behavior; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. While the record contains evidence of some of the symptoms listed in the criteria for a 100 percent rating or symptoms similar to those listed in the 100 percent rating criteria, including danger of harm to himself or others, and while the evidence reflects symptoms of auditory hallucinations and memory problems, these symptoms have not been shown to be so severe that they rise to the level of both total occupational and total social impairment. The Board acknowledges that, in this decision below, it has found the Veteran to be unemployable due to his service-connected disability. However, total social impairment has not been shown. "Total" is defined as "whole, not divided; full; complete," and "utter, absolute." Black's Law Dictionary, 1498 (7th ed. 1999). The Veteran has been able to maintain some personal relationships throughout the appeal period, to include a supportive partner relationship with his spouse. In this regard, a February 2000 VA treatment record reflects that the Veteran reported he has family members who look out for him and help him. An October 2004 VA treatment record reflects that the Veteran lived with his "lady friend" and that he helped take care of her child when she was working. A February 2005 VA treatment record reflects that the Veteran lived with his girlfriend and took care of her daughter at times while a June 2005 VA psychosocial treatment assessment, reflects the Veteran's reports that the relationship with his lady friend is good, that the relationship with his three children is good and they are off in college, and that he got along well with his lady friend's daughter. The October 2011 VA examination also reflects that the Veteran had a good relationship and reported that he got along well with one of his three children. Additionally, a February 2017 VA psychiatry treatment note reflects that the Veteran spent time with his grandchildren. The Board notes, however, that during the July 2017 VA examination, the Veteran reported that he does not see his children or grandchildren on a regular basis. The Board acknowledges the Veteran's reports of being a "loner" and that he is socially isolated and has no friends, but this is reflected in the now 70 percent rating for "deficiencies in most areas," the criteria for which includes the inability to establish and maintain effective relationships. While he was socially withdrawn and isolated, this evidence does not indicate total social impairment. Accordingly, because the Veteran is not totally socially impaired, a 100 percent rating is not warranted. Although the August 2011 VA examiner found the Veteran had total occupational and social impairment, this finding is inconsistent with the contemporaneous medical treatment records, to include the October 2011 examination findings. See also May 2011 VA treatment record (reflecting the Veteran's report that his medications were working for him, that his insight and judgment were good, and that he was assessed as being stable on his medication). As the examiner did not otherwise explain how he reached this conclusion or specifically detail how the Veteran's symptoms resulted in total occupational and social impairment, the Board gives this specific finding less probative weight and finds that the other evidence of record, detailed above, outweighs a finding of total social occupational impairment. Additionally, although the August 2019 private physician noted that the Veteran's spouse was essentially his caregiver and takes care of all his instrumental activities of daily living, the physician did not state that the Veteran was incapable of performing all of his instrumental activities of daily living. Moreover, the subsequent May 2020 VA examiner did not indicate that he Veteran's disability manifested in an intermittent inability to perform the activities of daily living, including maintenance of minimal personal hygiene, nor does the other VA examinations during the appeal period. The Board is sympathetic to the Veteran's belief that he is entitled to a higher rating and has considered his competent statements regarding is symptoms associated with his PTSD. The Board notes that it has no reason to challenge the credibility of these contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, the Veteran's reports describing his symptoms of suicidal ideation, paranoia, anxiety, hypervigilance, social isolation, chronic sleep impairment, worklike setting difficulties, and difficulty in establishing and maintaining effective work and social relationships are already reflected by the 70 percent rating. These lay statements do not provide a basis upon which to assign a higher rating because they do not reflect total social impairment. Moreover, the Board finds the objective clinical findings by medical professionals aware of his symptoms more probative than the Veteran's general assertions that his symptoms more nearly approximate a higher rating. The examiners are medical professionals, and they were able to review the overall record, including the Veteran's history and opinions. The examinations were provided to ensure that the record reflects the current extent of the disability, and these findings are responsive to the pertinent rating criteria. In sum, the Board finds that for the entire appeal period, the Veteran's psychiatric disorder manifested in symptoms most closely approximating occupational and social impairment with deficiencies in most areas. Accordingly, an initial rating of 70 percent, but no higher, for the appeal period prior to May 6, 2020 is granted; however, an initial rating in excess of 70 percent from May 6, 2020, is denied. 2. Entitlement to a TDIU from September 24, 1998, to October 9, 2019 Initially, the Board notes that the Veteran is in receipt of a TDIU for his service-connected disabilities from October 10, 2019. Additionally, because entitlement to a TDIU was raised during the pendency of the Veteran's initial increased rating claim for PTSD, his claim for TDIU is part and parcel of that increased rating claim under Rice, 22 Vet. App. at 455. As such, the pertinent appeal period under consideration is from September 24, 1998, the date of the Veteran's claim for service connection for PTSD, to October 9, 2019. VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from securing and following "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. 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). TDIU may be assigned where the schedular rating is less than total and it is found that the Veteran is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. 38 C.F.R. § 4.16(a). In determining unemployability for VA purposes, consideration may be given to a veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough, as a high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The 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, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). Medical evaluations are probative to understanding the level of functional impairment; however, the ultimate determination of unemployability is a legal question, not a medical one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Recently, in Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court defined the term "unable to secure and follow a substantially gainful occupation" in § 4.16(b) to include two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In the present case, in light of the Board's grant in this decision of an initial 70 percent rating for the Veteran's PTSD from September 24, 1998, the Veteran meets the schedular criteria for a TDIU for the appeal period. Specifically, the Veteran is service connected for PTSD with MDD and psychotic features (now rated as 70 percent disabling from September 24, 1998); left knee limitation of flexion (rated as 30 percent disabling from August 25, 2014); left knee strain with a history of acute inflammatory arthritis and tendonitis (rated as 20 percent disabling from June 6, 2002, 30 percent disabling from November 8, 2007, and 20 percent disabling from April 9, 2015), tinnitus (rated as 10 percent disabling from April 30, 1998), and right ear hearing loss (rated as noncompensable (0 percent) from August 6, 1976). Therefore, the threshold requirement for a TDIU rating on a schedular basis is met for the entire appeal period, and the remaining question is whether the Veteran's service-connected disabilities prevent him from securing or following a substantially gainful occupation. After review of the evidence and resolving any doubt in the Veteran's favor, the Board finds that for the applicable appeal period the Veteran was unable to obtain and maintain substantially gainful employment as due to his service-connected disabilities, to include his PTSD with MDD and psychotic features alone. In this regard, the evidence reflects that the Veteran attended college for approximately three and a half years after his first period of active duty service but did not complete his degree. See October 2011 VA examination; October 2019 TDIU application. Thereafter, following his separation from service, the evidence reflects that he worked in building maintenance, janitorial services, and as a mail clerk. See October 2019 TDIU application. He reported that he last worked full-time in May 1997 in janitorial services and became too disabled to work in March 1998. See id. Specifically, he reported that he was not fired, but he left the job because he felt that he was no longer able to carry out his duties. See May 1998 SSA disability evaluation. In this regard, he asserts that he had to medically retire in May 1997 due to his PTSD with MDD and psychotic features and that his PTSD symptoms, including panic attacks, memory impairments, and tiredness, affected his ability to work. See December 2019 Statement. The evidence of record confirms that the Veteran has remained unemployed for the entire appeal period. Additionally, an SSA earning statement record shows that the Veteran has no total earned income from 1999 through 2018. See October 2019 correspondence. The Board also notes that in February 1999, the Veteran was awarded SSA disability benefits with an established date of onset in May 1997 due to a number of disabilities, to include tinnitus, hearing loss in the right ear, insomnia, depression, PTSD, alcoholism, and drug addiction. In support of his TDIU claim, the Veteran submitted an October 1998 State of Alabama work requirement form, signed by a psychologist, reflecting that the Veteran was depressed, hospitalized the last time that he worked, and was not mentally and physically able to work. The Veteran also submitted a Temporary or Permanent Total Disability Certification, signed in December 1998 by a physician, certifying that the Veteran had a permanent psychiatric disability rendering him unable to work and earn money. Moreover, a February 2000 notification letter from a VA Vocational Rehabilitation Counselor states that his requested vocational/rehabilitation services would not be provided because the evidence in his case indicates that it was not reasonably feasible for him to achieve a vocational goal because providing him services would not result in him becoming employed. The medical documentation of record has provided further credibility to the Veteran's claim that his service-connected psychiatric disability is a major ability barrier to obtaining and maintaining substantially gainful employment. As detailed above, an October 1998 SSA assessment from a clinical psychologist reflects that the Veteran often had deficiencies of concentration and that he was moderately limited in his ability to work in coordination with or proximity to others without being distracted by them. As such, the psychologist found that the Veteran should not work in a job where contact with the public was a basic job requirement and recommended a work environment where the Veteran would have infrequent interaction with coworkers in a spaced work setting due to his mood and personality factors. The July 2007 VA examiner also found that the Veteran had severe impairment in social and industrial adaptability due to his psychiatric disorders. The August 2011 and September 2011 VA examiners found that the Veteran's disability manifested in difficulty in adapting to stressful circumstances, including work or a work like setting. Notably, after reviewing the Veteran's medical history, the August 2019 private psychologist found that the Veteran's psychiatric disability precluded substantially gainful employment. The private psychologist detailed the Veteran's symptoms, which included difficulty adapting to stressful circumstances, including work or a work like setting, and explained that the Veteran's near-continuous depression affected his ability to function independently, appropriately, or effectively. Likewise, the May 2020 VA PTSD examiner found that the Veteran's PTSD impaired his ability to handle stress, to trust anyone, to respond positively to criticism, and to adapt to change. The VA examiner noted that the Veteran had difficulty remembering verbal instructions, organizing and prioritizing tasks, learning new software programs/platforms, multitasking, and making friends or positive relationships at work. The VA examiner also found that the Veteran's MDD made it difficult for him to sustain concentration to complete assigned tasks and that absenteeism, generally, is increased by MDD. The examiner also noted that the Veteran's sleepwalking and his resulting sleep deprivation reduce his effectiveness in an occupational environment because he will be drowsy during the day, may nod off, and not have the stamina needed to complete his day's tasks, increasing his anxiety. This medical evidence indicates that the Veteran's PTSD with MDD and psychotic features, particularly his breaks in concentration and judgment as well as his challenges in working with others, ability to handle stress, and chronic sleep impairment, prevent him from performing the requirements of employment at any physical work level or for any other light employment. Although, the October 2011 VA examiner opined that the Veteran was capable of gainful employment, the examiner also noted that the Veteran would work best in a low social environment with casual and infrequent social interactions as well as in a moderate stress environment with moderate levels of task variability. Despite this conclusion, the overwhelming evidence indicates that it would be unlikely for the Veteran to find substantially gainful employment, or given his educational and employment history, unlikely for him to find employment under the work settings the October 2011 VA examiner found would work best for the Veteran. To the degree that he Veteran would be able to obtain employment, from a practical standpoint, the Board finds the Veteran would be too limited to perform such occupations as the totality of his mental health symptoms, including memory issues, chronic sleep impairment, disturbances in motivation and mood, also indicate the Veteran would be significantly impeded in workplace productivity based on his PTSD with MDD and psychotic features symptoms alone. Thus, in weighing the lay and medical evidence of record, as well as the Veteran's educational background and prior work experience, the Board finds that it is unlikely that the Veteran would have been able to find substantially gainful employment in another profession or field during the appeal period. Based on the foregoing, the Board finds that TDIU is warranted as the Veteran's service- connected disability precluded him from participating in any substantially gainful employment consistent with his education and work experience. Accordingly, entitlement to a TDIU from September 24, 1998, to October 9, 2019, is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Amanda Purcell, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.