Citation Nr: 21027768 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 12-28 793 DATE: May 6, 2021 ORDER Entitlement to an evaluation in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD), resulting in alcohol and substance abuse, from December 21, 2011 to August 22, 2018 is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to August 23, 2018 is denied. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran's symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 2. The Veteran's PTSD did not cause unemployability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2019). 2. The criteria for TDIU are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.340, 4.15, 4.16 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1969 to March 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in an April 2016 hearing. These issues were previously before the Board in August 2016, June 2020, and December 2020, each time remanded for further development. That development was completed, and the case has since been returned to the Board for appellate review. The Board finds there was substantial compliance with the December 2020 Board remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The December 2020 Board remand instructed the RO to obtain a retrospective medical opinion. The RO obtained an opinion in later that month. Based on that opinion, the RO granted an earlier effective date of August 2018 for the 100 percent evaluation for service-connected PTSD in a February 2020 rating decision. Accordingly, the Board will adjudicate these issues on appeal prior to August 2018. 1. Entitlement to an evaluation in excess of 50 percent for service-connected PTSD from December 21, 2011 to August 22, 2018 Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 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. 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 reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. The Veteran filed his claim for service connection for PTSD in November 2005, which was denied in an August 2006 rating decision. The Veteran appealed, and the Board granted service connection in a November 2011 decision. The RO effectuated this grant in a November 2011 rating decision, with a 50 percent evaluation effective the date of his original claim. The Veteran appealed this evaluation, and while on appeal, the RO granted a 100 percent evaluation prior to December 21, 2011, and maintaining the 50 percent evaluation on and thereafter in an April 2014 rating decision. The Veteran's service-connected PTSD is rated under 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula for Mental Disorders, the Veteran's current 50 percent evaluation contemplates 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, due to such symptoms as: suicidal ideations; 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 worklike setting); and the inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for a mental disorder when there is 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; and memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, DC 9411. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms; the length of remissions; and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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 the examination. 38 C.F.R. § 4.126 (a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). "[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." Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms shall have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio, 713 F.3d 112. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126. In addition, the evaluation must be 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 the examination. 38 C.F.R. § 4.126. During the appeal period, the Veteran underwent VA examinations in April 2012, October 2013, August 2015, and December 2017. The Veteran also attended regular therapy sessions at VA for a few years during the appeal period but stopped. In a December 2011 letter, the Veteran's VA psychiatrist explained that they treated him for PTSD. They noted that the Veteran had been prescribed numerous psychotropic medications, but tapered and discontinued Seroquel, an antipsychotic medication, because he was not suffering from psychosis, and the metabolic burden of the medication was potentially harmful considering obesity and diabetes. December 2011 VA treatment records note that the Veteran reported that he sleeps 4-5 hours per night, wakes up with nightmares once or twice a week, and that although his mood is not great, he denied depression. In a December 2011 statement, the Veteran stated that his daughter and her husband saved his life. He explained that his daughter gave up her full-time job for a part time one to feed him and give him his medication, and to take him to his VA appointments. The Veteran stated that prior to that he was homeless, could not think straight, had nightmares, drank and took drugs to sleep, and that he wanted to die. He asserted that due to the Seroquel, he was totally disabled from 2005 to 2009. During an April 2012 VA competency examination, the Veteran and his daughter asserted that he could manage his finances, and that he had been doing so for the previous three years. The examiner noted that the Veteran was calm, cooperative, and appropriate during the examination. His mood was euthymic with a mildly decreased range and intensity of affect. His speech was of normal rate and tone. He was awake, alert, and oriented to person, place, time, and situation. Abstract thinking was intact, thought processes were coherent, logical, and goal directed. There were no loose associations or flight of ideas. There was no sign of auditory or visual hallucinations, or delusional thoughts. The Veteran denied suicidal or homicidal ideation. The examiner found the Veteran's insight to be fair, and judgment intact. The examiner opined that the Veteran's psychiatric symptoms had stabilized since remission of the Veteran's substance dependence, and that while his PTSD symptoms included nightmares and anxiety, they did not render him incapable of managing his finances. December 2012 VA treatment records indicates that the Veteran had stable housing living with family, that he attended 12 step meetings occasionally, that his mood was stable, and that there were no neurovegetative signs of depression. The Veteran denied having delusions, hallucinations, and suicidal or homicidal ideation. He reported having to wake once per night to urinate, and that he sometimes had trouble falling back asleep. The Veteran stated that he has the occasional nightmare that he could dismiss easily. He reported that that his concentration was good, he enjoyed watching sports on television, and that he keeps up with his bills. The examiner noted that the Veteran was casually dressed with excellent grooming. He was calm and cooperative, and maintained good eye contact. His speech was normal in rate, rhythm and tone. His mood was good, with an affect that was broad, reactive, and appropriate. The examiner found the Veteran's thought processes logical and goal directed, his memory and orientation grossly intact, and his judgment and insight to be fair. On a depression checklist, the Veteran endorsed "not at all" for the following: little interest or pleasure in doing things; feeling down, depressed, or hopeless; feeling tired or having little energy; feeling bad about himself; trouble concentrating; moving or speaking slowly that other people have noticed; thoughts that he would be better off dead or hurting himself. He answered "more than half the days" for trouble falling or staying asleep. And he endorsed "several days" for poor appetite or overeating. The Veteran underwent a VA examination in December 2013 where the examiner noted diagnoses of PTSD, alcohol and cocaine dependence in full sustained remission. The examiner was able to differentiate the symptoms between the three diagnoses, explaining that the PTSD causes nightmares, anxiety, hypervigilance, easy startle, and avoidance, while the substance abuse was in full remission, so it no longer contributed to the symptoms. The examiner noted that the Veteran had occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. They noted that the Veteran had been discharged from the VA substance abuse program in 2012 after several years of sobriety and success, and that he took medication for nightmares. The examiner found persistent PTSD symptoms included difficulty falling or staying asleep, anxiety, and irritability or outbursts of anger more than once a month, and that these symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner opined that previously, the Veteran's mood swings were caused by substance abuse, that the PTSD is more likely than not at the milder end of the spectrum, and that the Veteran was certainly higher functioning at the time of the examination that he was in 2008. In a July 2014 statement, the Veteran asserted that he should receive a disability rating higher than 50 percent because he still has a lot of nightmares. The Veteran began attending therapy sessions at VA in July 2014 after relapsing and using cocaine as a result of depression. These sessions continued regularly through August 2017. Generally, at these sessions, the Veteran reported his mood to be up and down, and often expressed frustration about his appeal. He consistently denied suicidal or homicidal ideation, and reported occasional nightmares and difficulty sleeping. The examiners generally found his speech to be of slow rate, and low volume, with a normal prosody, tone, and rhythm. They found that the Veteran did not have delusions or hallucinations, that his thought processes were linear and logical, that his memory and orientation was intact, that his attention was grossly intact with some mild appearance of mind-wandering. Initially, the Veteran continued to abuse cocaine, and the examiners found the Veteran's insight and judgment ranged from poor to fair and improving but clouded by substance abuse. In May 2015, the Veteran asserted that a friend of his was shot and killed by the police, and examiners found that he had appropriate perseveration on his friend's death. In July 2015, the Veteran asserted that he was friends with a couple people who were murdered by a gunman in a recent church shooting, and that he was also upset over a neighbor who died suddenly of a heart attack. In October 2015, the Veteran reported feeling depressed every couple of weeks. In July 2016, the Veteran reported that he avoided places with flashing lights, sirens, or fireworks, but that anxiety was not a problem during that session. By January 2015, the Veteran denied continued substance abuse. By November 2015, the examiners began to find the Veteran's insight and judgment to be fair. In an October 2014 statement, the Veteran's sister asserted that the PTSD symptoms and nightmares had gotten worse. She explained that she sometimes had to wake him because of his nightmares, and that his sleep habits were getting worse. The Veteran underwent a VA examination in August 2015 where the examiner noted diagnoses of PTSD, and cocaine and alcohol use disorder, and opined that they were unable to differentiate the symptoms because they overlapped. There, the Veteran reported that he resided with his sister. He explained that his relationships with his sister, and his two children are fine. He stated that he watches television, does chores, visits his daughter and grandchildren, and goes to church twice a month. He denied having an active social life because his friends were killed by police, or by a gunman in the church shooting. The examiner declined to provide an opinion about the Veteran's ability to work because they did not deem him to be a reliable historian because he reported symptoms at a more severe level than indicated by the treatment records, and that he was not forthcoming about his recent cocaine and alcohol use; however, they did opine that he would likely find it challenging to obtain or sustain employment on his own. The examiner noted that the Veteran asserted that he was not sleeping well and that his nightmares were getting worse due to the recent killings. The examiner found that the Veteran's symptoms included the following: depressed mood; anxiety; chronic sleep impairment; mild memory loss; flattened affect; impaired judgment; disturbances of motivation and mood; difficulty establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a work like setting. The examiner opined that the Veteran met the minimum criteria to meet a diagnosis of PTSD, and that this was consistent with the 2012 VA examination. During the April 2016 Board hearing, the Veteran asserted that the doctor who treated him did not agree with the 50 percent evaluation. The Veteran asserted that his PTSD is getting worse, that he still took medication for treatment, and that he had nightmares, impaired sleep, and a lot of mood swings. He explained that his relationships can be good and bad at times, and that sometimes his family came to visit, and at other times he feels irritable wanted to be by himself. He also reported that he lived with his sister, and that his relationship with her was pretty good, as it was with other family members too, but that he did not have a lot of friends or social activities. He stated that he cannot stand loud noises, and that he was worried someone might break in. He stated that he hallucinated a lot during his sleep, and he thought that people are trying to hurt him. The Veteran asserted that he cannot stand movies where people get shot. He explained that on a typical day, he would wake around 4 or 5 in the morning, read the newspaper, mess around the house, and go for a walk, and that he did not socialize much. The Veteran also denied suicidal and homicidal ideation. The Veteran underwent a VA examination in December 2017 where the examiner provided diagnoses of PTSD, and cocaine and alcohol abuse, and opined that it was not possible to differentiate the symptoms of the diagnoses because they overlap and interact with each other. The examiner found that the Veteran had occupational and social impairment with reduced reliability. The examiner found that the Veteran's symptoms included the following: depressed mood; anxiety; chronic sleep impairment; mild memory loss; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances. During the examination, the examiner found the Veteran to be clean, his speech unremarkable, his attitude cooperative, his mood depressed, and his affect congruent with his mood. His attention and orientation were intact. His thought processes were unremarkable, he had no delusions or hallucinations, and he had good insight and judgment. The examiner noted that the Veteran was sleep impaired, but that he did not have any obsessive or ritualistic behavior. The examiner found that the Veteran had no inappropriate behavior, that his impulse control was good, that he was not violent, that he was able to maintain personal hygiene and other activities of daily living, and that he was capable of managing his financial affairs. Prior to August 23, 2018, the Board finds that the Veteran's service-connected PTSD with alcohol and cocaine abuse have not more nearly approximated a 70 percent evaluation. First, although an August 2015 VA examination showed impaired judgment, the remainder of the evidence showed intact or good judgment. The Veteran's thoughts were intact, coherent, and logical. The evidence of record does show deficiencies in mood. Additionally, VA examinations and treatment records demonstrate difficulty in adapting to stressful circumstances. The evidence does not, however, show an inability to establish and maintain effective work and social relationships, as the Veteran retains good relationships with his family. Furthermore, the evidence shows the Veteran was fully oriented and he exhibited good hygiene. The Veteran also consistently denied suicidal and homicidal ideations, delusions, and hallucinations. Although the Veteran at times expressed that he was irritable with his family at times, he also reported that he had good relationships with his sister and his two children. He explained that he went to church often and liked to visit with his daughter and grandchildren. The Veteran has reported that while he has difficulty sleeping, he wakes in the morning to read the newspaper and go for walks. Accordingly, entitlement to an evaluation in excess of 50 percent for service-connected PTSD with alcohol and cocaine abuse prior to August 23, 2018 is denied. 2. Entitlement to a TDIU prior to August 23, 2018 is remanded. In a September 2017 statement, the Veteran asserted that he has been unable to work since 2005. In an October 2019 statement, the Veteran asserted that he has tried very hard to get another job, but no one would hire him due to his PTSD. He also stated that his other non-service-connected health issues did not come until many years after his retirement. In a June 2019 statement, the Veteran asserted that the United States Office of Personnel Management (OPM) told him to retire at the age of 44 because of his PTSD, drinking, and drug use. A January 1995 OPM letter confirms that the Veteran began receiving disability payments. VA will grant TDIU when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU is granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. 38 C.F.R. § 4.16(a). If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). 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. 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). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the veteran's background including his employment and educational history. 38 C.F.R. §§ 3.321(b), 4.16(b). The Board does not have the authority to assign an extraschedular TDIU rating in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rather, the issue must be referred to the Director of Compensation Service for such assessment in the first instance. Kuppamala v. McDonald, 27 Vet. App. 447, 457 (2015). Thereafter, the Board has jurisdiction to review the entirety of the Director's decision denying or granting an extraschedular rating and is authorized to assign an extraschedular rating when appropriate. Kuppamala, 27 Vet. App. at 457. For VA purposes, the term unemployability is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91, 57 Fed. Reg. 2,317 (Jan. 21, 1992). Consideration may be given to the veteran's education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but 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, 4 Vet. App. at 363. The ability to work sporadically or obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). Service connection is in effect for PTSD with alcohol and cocaine abuse. For the time period on appeal, the Veteran's combined disability evaluation is 50 percent. Thus, the percentage requirements for a TDIU are not met because the Veteran has one service-connected disability, but it is not rated as 60 percent or higher. 38 C.F.R. § 4.16(a). After a review of the evidence of record, the Board finds that referral for consideration of entitlement to a TDIU on an extraschedular basis is not warranted as the evidence does not show unemployability from 2011 to 2018. Regarding education and experience, the Veteran has a high school education, and according to his DD-214, during active duty service his military occupational specialty (MOS) was salesclerk. August 2005 VA treatment records indicate that the Veteran worked at VA in housekeeping services for 21 years. March 2008 VA treatment records note that the Veteran was retired on disability since 1995 due to anxiety attacks, and that he had no employment since. Social Security Administration (SSA) records from 2004 indicate that the Veteran does not retain the capacity for past relevant record due to mental problems, since he stopped working in December 1994 when he was hospitalized. June 2005 VA treatment records note that the Veteran should be able to start in a work program. Notably, prior to 2011, the Veteran was rated at 100 percent, which recognizes the severity of the Veteran's PTSD at that time. However, after, the Veteran's 50 percent rating does not reflect such severity. Much of the relevant lay and medical evidence has been noted above. On an October 2013 VA mental health issues disability benefits questionnaire (DBQ), a VA examiner noted 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, or symptoms controlled by medication. The examiner opined that all the disability level is caused by PTSD. At a VA examination in December 2013, the examiner opined the Veteran had occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The examiner found persistent PTSD symptoms that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner opined that previously, the Veteran's mood swings were caused by substance abuse, that the PTSD is more likely than not at the milder end of the spectrum, and that the Veteran was certainly higher functioning at the time of the examination that he was in 2008. During the August 2015 VA examination, the examiner declined to provide an opinion about the Veteran's ability to work because they did not deem him to be a reliable historian because he reported symptoms at a more severe level than indicated by the treatment records, and that he was not forthcoming about his recent cocaine and alcohol use; however, they did opine that he would likely find it challenging to obtain or sustain employment on his own. The examiner also found that the Veteran's PTSD was manifested by difficulty establishing and maintaining effective work and social relationships and in adapting to stressful circumstances, including work or a work like setting; the examiner did not, however, show an inability of such. In an October 2017 letter, the Veteran's VA doctor opined that the Veteran is disabled to the non-service-connected diabetes mellitus type II (DMII), hyperlipidemia, degenerative joint disease, hypertension, dermatitis, deep vein thrombosis, obstructive sleep apnea, and hepatitis. During the December 2017 VA examination, the examiner noted that the Veteran has occupational and social impairment with reduced reliability. The examiner also found that the Veteran's PTSD was manifested by difficulty establishing and maintaining effective work and social relationships and in adapting to stressful circumstances, including work or a work like setting; the examiner did not, however, show an inability of such. The Board finds that referral for extraschedular consideration is not warranted. The evidence of record does not demonstrate an inability to obtain substantially gainful employment due to PTSD. Although the Veteran's PTSD does cause significant impairment, the examiners have unanimously found that it does not cause an inability to work. The Veteran's PTSD was more severe prior to 2011, and from 2011 to 2018, it did not preclude substantially gainful employment. Although the Veteran's physician found him unable to work, this conclusion was based upon non-service-connected disabilities. Accordingly, the Veteran's claim for TDIU is denied. K. MILLIKAN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rogos 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.