Citation Nr: 21026937 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 19-34 774 DATE: May 4, 2021 ORDER Entitlement to an initial disability rating in excess of 30 percent for PTSD prior to June 3, 2019 is denied. Entitlement to a disability rating in excess of 70 percent for PTSD from June 3, 2019 is denied. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) prior to June 3, 2019 is denied. FINDINGS OF FACT 1. Prior to June 3, 2019, the probative evidence of record shows that the symptoms of the Veteran's PTSD manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). 2. From June 3, 2019, the probative evidence of record shows that the Veteran's PTSD has not been manifested by total social impairment. 3. From February 11, 2015 to June 2, 2019, the Veteran's combined schedular disability rating did not meet the minimum percentage requirements in 38 C.F.R. § 4.16(a) for consideration of a TDIU on a schedular basis, and the Veteran's service-connected disabilities did not render him unable to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased initial rating in excess of 30 percent for PTSD prior to June 3, 2019 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to an increased rating in excess of 70 percent for PTSD from June 3, 2019 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411. 3. The criteria for entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) prior to June 3, 2019 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341(a), 4.16, 4.19, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1966 to March 1968. This matter comes before the Board of Veterans' Appeals (Board) from a November 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in July 2020 and February 2021. In July 2020 the Board remanded the case so that Vet Center and VA treatment records could be obtained, and so he could provide a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). He submitted the form in July 2020. Updated VA treatment records were associated with his claims file. In February 2021 the Board remanded the issues again so that the Veteran's outstanding VA treatment records from the Vet Center in Marietta, Georgia for the period of January 2017 forward. Such medical records have been obtained and associated with the claims file. Therefore, there has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. "Staged" ratings are appropriate for an increased rating when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Given the nature of the present claim for a higher initial evaluation, the Board has considered all evidence of severity since the effective date for the award of service connection on February 11, 2015. Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 1. PTSD The Veteran contends that his PTSD warrants higher ratings than that currently assigned. The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Codes 9204-9411, with an initial rating of 30 percent from February 11, 2015 until June 2, 2019 and a 70 percent rating on and after June 3, 2019. Hyphenated diagnostic codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. However, in this case, Diagnostic Code 9204 is no longer in use. Diagnostic Code 9411 pertains to PTSD. Under 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 provides that a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, or recent events). 38 C.F.R. § 4.130. A 50 percent rating is assigned 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 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affected 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 situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought process or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including the maintenance of minimal personal hygiene); disorientation as to time and place; and memory loss for names of close relatives, occupation, or own name. Id. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA 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(b). Prior to June 3, 2019 The Veteran contends that he is entitled to an initial rating in excess of 30 percent from February 11, 2015 to June 2, 2019. In a November 2015 rating decision, the Veteran was granted service connection for PTSD with an evaluation of 30 percent effective February 11, 2015 (the date the Veteran's Fully Developed Claim was received). At an October 2015 VA examination, the examiner opined that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the DSM-5 criteria. At this time, the examiner characterized the Veteran's diagnosis as being other specified trauma- and stressor-related disorder and unspecified depressive disorder. The examiner reported that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. At his VA examination, the Veteran reported that he and his wife had been sleeping in separate rooms for the past two years because "she says [he] groan[s] in his sleep, like [he is] hollering out or something." At this time, the Veteran has reported some avoidance, sleep disturbance, hypervigilance as well as a depressed mood. He reported having been married to his first and only wife for 46 years. They had three adult children and eight grandchildren. He enjoyed spending time with his family, working on old cars, attending church, and attending local VFW gatherings. His primary psychiatric complaint was intrusive memories of stressors in Korea, avoidance, sleep disturbance, hypervigilance, and depressed mood. He did not take medication at the time of the examination. The Veteran's symptoms were anxiety and chronic sleep impairment. At the examination, he was alert and oriented. His mood was euthymic, which is defined as "a state of mental tranquility and well-being; neither depressed nor manic." Dorland's Illustrated Medical Dictionary, 655 (32nd ed. 2012). His thought processes and content were normal. His insight was fair and his judgment was within normal limits. In a January 2016 VA Mental Health Integration Progress Note, the Veteran described experiencing heightened anxiety and sleep difficulty since the occurrence of a disturbing experience at work. The Veteran related this experience to specific experiences he had while in the military. In a July 2016 VA Mental Health Integration Progress Note, the Veteran reported having a panic attack in the last week while he was at home. At this time, the Veteran indicated that he had been thinking about the service at the time, specifically handling dead bodies. The examiner observed that the Veteran reported the frequency of the panic symptoms in the past as "a couple times per week" but it appears that it had been a few months since he had experienced panic symptoms. In July 2016, the Veteran continued to complain of nightmares, and his wife reported that he "hollers at night," but he often has no memories of these episodes. The Veteran also reported that he does try to seek support but does not like to discuss his specific distressing military experiences. In the July 2016 Progress Note, the examiner described the Veteran's appearance as being reasonable/cooperative and appropriate. The examiner also reported that the Veteran's thought process was normal, his judgment and insight were good, and that he did not have suicidal/homicidal ideation or aggressive thoughts. At a September 2016 psychotherapy session, he reported being anxious in traffic and high speed areas. He stated that he felt weak sometimes and did not trust people fully. The therapist noted he had deep connections with his family. He had difficulty speaking about his emotions. In January 2017, the Veteran began attending group therapy at the Veteran's Center in Marietta, Georgia. At his January 2017 intake assessment, the examiner noted that the Veteran was married with grown children and grandchildren with whom he has an extremely close relationship. At this time, the Veteran presented with self-blame and guilt feelings related to most life stressors. The Veteran also stated that he and his wife do not sleep together because he yells and screams out while asleep, and that his family views him as overly sensitive. At the January 2017 intake assessment, the Veteran's appearance was neat, and his manner was friendly and cooperative. The Veteran's memory function was normal and his affect appropriate. The Veteran did not present with delusions, disorganized thinking, hallucinations, or grossly disorganized catatonic behavior. The Veteran also presented with a depressed mood, though he did not have any suicidal or homicidal thoughts at the time. The Veteran was afforded a PTSD examination in June 2018, provided by a private psychologist. The psychologist diagnosed PTSD and major depressive disorder (moderate, recurrent with anxious distress). The psychologist said it was not possible to differentiate the symptoms of his PTSD and depressive disorder. All of his psychiatric symptoms are considered to be service-connected. Mittleider v. West, 11 Vet. App. 181, 182 (1998). The psychologist listed the Veteran's symptoms for rating purposes as being depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; flattened affect; circumstantial, circumlocutory or stereotyped speech; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The psychologist concluded that the PTSD resulted in total occupational and social impairment. Further, the psychologist opined that there is objective empirical evidence from the Veteran's psychological testing and clinical interviews that his symptoms are very pervasive in his life at this time, and that this array of symptoms significantly impairs multiple aspects of his life functioning. The examiner also concluded that the Veteran's diagnosis causes clinically significant distress and impairment in social, occupational, and other important areas of functioning. Progress notes from the Veteran's group therapy sessions dating back to February 2017, March 2017, May 2017, March 2018, April 2018, May 2018, July 2018, August 2018, September 2018, October 2018, November 2018, December 2018, January 2019, February 2019, March 2019, April 2019, and May 2019 demonstrate that the Veteran was interactive and appropriately dressed and groomed. Throughout these sessions, the Veteran was described as being alert, cooperative, and oriented. At these sessions, the Veteran's memory was noted as being intact with good judgment and insight with an organized thought process. He also did not display any suicidal or homicidal intentions at these sessions. Based on the above, the Board finds that the Veteran's PTSD symptoms prior to June 3, 2019 have been evidenced by sleep impairment, depressed and anxious moods, and memory impairment. The Board finds that these symptoms more closely approximate the criteria for a 30 percent because they result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. An initial 30 percent rating for PTSD prior to June 3, 2019 is therefore appropriate. Depressed and anxious moods are contemplated by the 30, 50 and 70 percent rating criteria. However, simply because the Veteran has depressed and anxious moods, and because the 50 percent level contemplates "disturbances of motivation and mood," and the 70 percent level contemplates "deficiencies in most areas, such as mood[,]" does not mean his PTSD rises to the 50 or 70 percent level. The 30 percent criteria contemplate "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as: depressed mood [and] anxiety[.]" The Board, instead, must look to the frequency, severity, and duration of the impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Here, the Veteran's depressed and anxious moods are expressly contemplated by the 30 percent criteria. The Veteran is adequately compensated for that impairment. The frequency, severity, and duration of his feelings of anxiety and depression are not such that they cause reduced reliability and productivity. The record shows that he was independent in his activities of daily living, competent to manage his funds, and did not require assistance for tasks due to his psychiatric symptoms. The record did not show that he was unreliable or could not be trusted. He was able to volunteer one day per week at a Veterans Service Organization and did not state that he was unreliable, unproductive, or untrustworthy while performing volunteer work. At a May 2018 social work appointment, the Veteran stated that he volunteered once per week and that he felt better when he was engaged. He stated that he was recognized for his volunteer work. While the psychologist at the June 2018 VA examination opined that the Veteran's diagnosis causes clinically significant distress as well as both total social and total occupational impairment, this finding is inconsistent with progress notes from the Veteran's group therapy sessions from that time. During this period, the Veteran's group therapy progress notes describe him as being interactive, alert, cooperative as well as appropriately dressed and groomed. Additionally, they did not show total social impairment. For example, in August 2018, he reported having a "good relationship" with his wife. He was able to attend a wedding with several family members. He was open to his therapist's suggestion that he join a group to discuss classic cars. in May 2019, he reported a "good relationship with [his] wife." His son lived nearby and visits occasionally. He also went to the Y every other day, enjoyed a fellowship with other veterans at the Vet Center, and volunteered at an unemployment office once a week. The 70 percent criteria contemplate "near continuous" depression or panic that affects the ability to function independently, appropriately, and effectively. For the period before June 3, 2019, the record does not show that the Veteran's depression and anxiety impacted his ability to function independently, appropriately, and effectively. His depression and anxiety were not of the severity that is contemplated by the 70 percent criteria. Additionally, his depression and anxiety were not near-continuous. For example, at a November 2018 appointment, he stated that he had "periods of depression." The probative evidence of record does not show that the particular symptoms associated with the higher percentage or others of similar severity, frequency, and duration result in occupational and social impairment with reduced reliability and productivity. A 50 or 70 percent rating is not warranted. Vazquez-Claudio, 713 F.3d at 114 (holding that a veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). From June 3, 2019 The Veteran contends that he is entitled to a rating in excess of 70 percent from June 3, 2019. The Veteran's service connected PTSD was increased to 70 percent disabling effective June 3, 2019, the date of the VA examination that showed a worsening of his condition. The Veteran was also granted entitlement to a TDIU due to his service connected disorders effective June 3, 2019. At the June 3, 2019 VA examination, the examiner noted that the Veteran had occupational and social impairment with reduced reliability and productivity. At this time, the Veteran stated he has been married for over 50 years. The Veteran reported that he had not slept in the same room as his wife for the past few years due to restlessness while sleeping, yelling out, and moving his arms around. The Veteran also stated that he has become angrier and more irritable around others. At the June 2019 examination, the Veteran stated that he had to quit his job in 2016 because he had difficulty getting along with others. The Veteran also recalled having problems with remembering dates and numbers, leading him to missing deadlines at work often. The examiner observed that no educational changes were reported at this time. The Veteran also stated that he attends weekly group therapy sessions at the Veteran's Center, and that he meets with a VA social worker every two months. The examiner concluded that while the Veteran acknowledged suicidal thoughts, he denied any current imminent plan to harm himself. Ultimately, the examiner opined that the Veteran does not appear to pose any threat of danger or injury to self or others. The examiner also noted that the Veteran reported a tendency of self-isolation that has become worse, and that he does not socialize with his family and remans quiet around them and avoids family activities. The examiner listed the Veteran's symptoms for rating purposes as anxiety; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; disturbances of motivation and mood; difficulty adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; and suicidal ideation. The issue was remanded by the Board in July 2020 for further development. The Agency of Original Jurisdiction (AOJ) was instructed to obtain the Veteran's VA treatment records for the period of October 2019 forward. Such records were obtained and associated with the claims file and an SSOC was issued in February 2021. A VA Psychiatry General Progress Note from November 2019 reflects that the Veteran reported doing well but wanting to be by himself. He also complained about being forgetful. Specifically, the Veteran stated that he has three children and eight grandchildren and sometimes he cannot remember or mixes up their names. At this time, the Veteran reports that his sleep has been fair, but he has middle insomnia at times. The examiner observed that the Veteran was not exhibiting symptoms of mania/hypomania or psychosis. The Veteran denied suicidal and homicidal ideations. The Veteran also reported having a good relationship with his wife and was looking forward to spending Thanksgiving with his family. At this time, the examiner observed that the Veteran was alert, dressed appropriately, and had good hygiene. The Veteran's motor activity was characterized as being calm with no abnormal movements noted. The Veteran was described as being cooperative, pleasant, engaging, and polite. The examiner noted that the Veteran was tired at the time of the appointment and that his concentration and memory were normal. The examiner also observed that the Veteran's judgment and insight were good, and that he was oriented as to person, place, situation, and date. The Veteran had an appointment with his VA social worker in January 2020. The social worker observed that the Veteran was easily engaged and openly communicated, and that he maintained good eye contact. At this time, the Veteran stated that he was doing "alright," and the social worker observed that his affect was flat. The Veteran stated that he continued to attend group therapy sessions at the Marietta Veteran's Center on Thursday. The Veteran also reported volunteering every Wednesday, and that "it feels good to be with the guys. I enjoy helping people." The Veteran stated that his constructive activities help with his mood. The social worker observed that the Veteran has supportive family and friends and is engaged in constructive activities. At his January 2020 appointment, the Veteran observed that his memory was "not good." Specifically, the Veteran reported being unable to remember "names and stuff like that." The Veteran reported feeling a little depressed at this appointment, but the social worker noted that the Veteran did not have homicidal or suicidal ideations and no unmet needs were identified. The social worker also observed that the Veteran's attention/concentration was sufficient, and he was alert, orientated, engaged and active. In a March 2020 Psychiatry General Progress Note, the Veteran reported that his mood has been fair and stated that he was getting six to seven hours of sleep per night. The Veteran also stated that he stays busy with a "lot of volunteer work" with the labor board for Disabled American Veterans. The Veteran reported that he enjoys the fellowship with other veterans. The Veteran stated that he still attends weekly group therapy sessions every Thursday. At this time, the Veteran denied symptoms of mania/hypomania or psychosis and denied suicidal and homicidal ideations. The Veteran stated he was feeling depressed but has been able to talk to his wife more, which has been helpful. The Veteran also reported intermittent dreams. The examiner observed that the Veteran was alert, dressed appropriately, and had good hygiene. The examiner also noted that the Veteran was calm and did not exhibit any abnormal movements. The Veteran was described as being cooperative, pleasant, engaging, and polite. The examiner noted that the Veteran was in a good mood and had restricted affect, and that his attention and concentration were normal. The examiner observed that, in terms of his recent memory, the Veteran was forgetful at times. The Veteran was noted as not having any auditory or visual hallucinations or delusional thoughts. In a Mental Health Triage Note dated April 2020, the examiner observed that the Veteran presented with a normal mood and broad affect. At this time, the Veteran reported that he missed volunteering and engaging with his Veteran friends. The examiner observed that the Veteran has supportive family and friends and is engaged in constructive activities. At this time, the examiner noted that the Veteran was alert, oriented, and easily engaged, and did not have homicidal or suicidal intent. Based on the evidence described above, the Board does not find the criteria for a 100 percent evaluation are more nearly approximated by the Veteran's symptoms at any point after the June 3, 2019 VA examination. If viewed in the light most favorable to the Veteran, the record contains evidence of memory impairment, which is contemplated in the 100 percent rating criteria. However, even the constant present of some symptoms listed in the criteria for a 100 percent rating is insufficient because the overall guiding criterion for a 100 percent rating is that both total occupational and total social impairment be present. 38 C.F.R. § 4.130; see, e.g., Vazquez-Claudio, 713 F.3d at 117. In this case, the Veteran's symptoms have not been shown to be so severe that he has both total occupational and total social impairment. In this decision, the Board has found the Veteran to be totally occupationally impaired since the grant of a TDIU effective June 3, 2019. However, total occupational impairment is not sufficient to warrant a 100 percent rating because total social impairment is not present. "Total" is defined as "whole, not divided; full; complete," and "utter, absolute." Black's Law Dictionary, 1498 (7th ed. 1999). With regard to social impairment, the Veteran has been able to maintain some personal relationships, specifically with his spouse of over 50 years, children, grandchildren, and those he volunteers with. The Board acknowledges that these relationships are sometimes strained or distant, but that is reflected in the current 70 percent rating for "deficiencies in most areas," which contemplates symptoms including inability to establish and maintain effective relationships. The Veteran is not completely or absolutely socially impaired. Because the Veteran is not totally socially impaired, a 100 percent rating is not warranted. The Board notes that many of the Veteran's reported symptoms since the June 3, 2019 VA examination are included among those specifically listed in the General Rating Formula for Mental Disorders, pursuant to which a 70 percent disability rating has been assigned. See 38 C.F.R. § 4.130. Importantly, the Board notes that symptoms noted in the rating schedule are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, symptoms comparable to those listed in the General Rating Formula could be used in evaluating the extent of the Veteran's occupational and social impairment. Accordingly, in this case, the Board finds that the existence and severity of the Veteran's psychiatric symptoms are adequately contemplated by the 70 percent rating criteria. As noted above, many of the symptoms are specifically listed in the General Rating Formula for Mental Disorders, and the others are common psychiatric symptoms that while not specifically listed are comparable indicators of the type of occupational and social impairment contemplated in the Rating Formula. In sum, the Board finds that, resolving reasonable doubt in the Veteran's favor, his impairment due to PTSD has been most consistent with a 70 percent disability rating since June 3, 2019. 2. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) prior to June 3, 2019 The Veteran contends that he is entitled to a TDIU for the entire appeal period. Entitlement for a TDIU was granted in a November 2020 rating decision, effective June 3, 2019. The Veteran's current combined disability rating is as follows: 30 percent from February 11, 2015, 40 percent from March 13, 2015, and 70 percent from June 3, 2019. The Veteran became entitled to a schedular TDIU on June 3, 2019. All veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of service-connected disability shall be rated totally disabled. For VA purposes, total disability exists when there is any present impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.16. A total disability rating for compensation may be assigned, where the schedular rating is less than total, when a veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of 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. § 4.16. Nevertheless, even when the percentage requirements are not met, entitlement to TDIU on an extra-schedular basis may be granted in exceptional cases when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). "Substantially gainful employment" is defined as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran's earned annual income. See Faust v. West, 13 Vet. App. 342 (2000). The determination as to whether a TDIU is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-32 (1991). Age may not be considered as a factor in evaluating unemployability. 38 C.F.R. §§ 3.341, 4.19. The veteran's service-connected disabilities, employment history, education and vocational attainment, and all other factors bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). In order to prevail on an extraschedular basis, the record must reflect some factor that takes the case outside the norm. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether one can find employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. See 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). For VA purposes, the term "unemployability" is synonymous with the inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91, 57 Fed. Reg. 2317 (Jan. 21, 1992). At his June 2019 examination, the Veteran stated that he had to quit his job in 2016 because he had difficulty getting along with others. The Veteran also submitted a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) in July 2020. He noted that his dates of employment were from February 1989 to June 2016. The Veteran also states that the date he became too disabled to work was in June 2016. In his VA Form 21-8940, he stated that he left his job because of his PTSD. The evidence of record demonstrates that the Veteran has not engaged in full-time employment since 2016. The term "substantially gainful occupation" is not defined in the rating schedule. Rather, the Court in Ray v. Wilkie, found the phrase has two components: an economic one and a noneconomic one. 31 Vet. App. 58 (2019). In assessing the Veteran's ability to secure and follow a substantially gainful occupation, the Board is to consider the Veteran's history, education, skill, and training as well as physical abilities and mental abilities required by the occupation at issue. Id. Such specific physical ability-factors include lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory, and visual. Id. Specific mental ability-factors include memory, concentration, ability to adapt to change, handle work-place stress, getting along with coworkers, and demonstrating reliability and productivity. Id. In his VA Form 21-8940, the Veteran reported that he worked at Walmart in the field of retail from 1989 until June 2016. He had a high school education. In an October 2015 VA treatment record, he stated that he had been employed at Walmart in a managerial role until 2002, when he had heart surgery and needed to reduce the stress on his heart. As a result, he worked as an assistant manager. The examiner found that his PTSD would decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The evidence of record does not show that the Veteran's PTSD created any physical barriers to employment. He has not contended, nor does the evidence show that his other service-connected disability, GERD, caused any physical barriers to employment. The October 2015 and June 2018 examiners stated that the Veteran had "difficulty" establishing and maintaining effective work and social relationships and "difficulty" adapting to stressful circumstances, including work or a work-like setting. Difficulty at work is contemplated by virtue of the disability ratings assigned for his PTSD. 38 C.F.R. § 4.1. Additionally, the Veteran's lay statements regarding why he stopped working do not indicate that relationships were why he retired from his career at Walmart. At a June 2016 VA appointment, he stated that he had a hard time concentrating, and that this was one of the reasons he retired. He stated that he had problems remembering things at work and "keeping up with things" and this preventing him from "functioning his best on the job." The record shows that prior to June 3, 2019, his memory loss was mostly mild or not present. The October 2015 and June 2018 VA examiners categorized his memory impairment as "mild." At a July 2016 VA comprehensive mental health assessment note, he did not have any obvious cognitive impairment. At his mental status examination, his ability to pay attention and concentrate was "sufficient," but he reported that his immediate memory was impaired. Two August 2018, two September 2018, and one October 2016 VA therapy notes show that his ability to pay attention and concentrate was sufficient and that he reported his memory was intact. In December 2016 he reported his memory as a barrier to learning. In January 2018, he reported memory loss, and was advised to take vitamin D, fish oil, and occasional vitamin b12. The examining clinician noted that his thyroid stimulating hormone should be checked and he should return to the clinic in 7-9 months if the memory loss persisted. This supports a finding that the January 2018 report of memory loss was associated with a thyroid problem and not his service-connected PTSD. At March 2018, April 2018, May 2019, June 2018, August 2018, October 2018, November 2018, and February 2019, his memory was normal and he was able to pay attention and concentrate. Prior to June 3, 2019, his memory difficulties were mild or were not present. The Veteran's mild memory loss is not a mental barrier that precludes employment. He reported retiring because he was no longer functioning his best, and this is not the standard for a finding of unemployability. He is assigned disability ratings for his PTSD and GERD. Disability ratings are assigned to represent, "...as far as can practicably be determine the average impairment in earning capacity resulting from such diseases and injuries in [veterans'] civil occupations." 38 C.F.R. § 4.1. His disability ratings acknowledge that he may not be able to perform at his best at his job. The memory loss shown in his records does not rise to a level that prevents him from working. The Veteran does not state that any of his other PTSD symptoms are the reason he is unable to work in the field of retail. (Continued on the next page) Because the record does not indicate that the Veteran's service connected PTSD or GERD prevent him from working in the field of retail, the claim for a TDIU prior to June 3, 2019 should not be submitted for extraschedular consideration and is denied. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. DeVerter, 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.