Citation Nr: 21029129 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-33 612 DATE: May 12, 2021 ORDER The claim of entitlement to an initial rating of 70 percent, but no higher, for service-connected posttraumatic stress disorder (PTSD) is granted. The claim of entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. The Veteran's PTSD manifested with symptoms most closely analogous to occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but did not rise to the level of total occupational and social impairment. 2. Resolving reasonable doubt in favor of the Veteran, his service-connected disabilities render him unable to obtain or maintain a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for establishing entitlement to TDIU benefits have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Army from January 2010 to January 2011 and October 2011 to November 2012. The instant matter is on appeal from a May 2013 rating decision. The Board previously granted entitlement to a 50 percent rating, but no higher, for service-connected PTSD in a May 2019 decision. The Veteran appealed this determination to the Court of Appeals for Veterans Claims (Court), which vacated the decision pursuant to a Joint Motion for Remand (JMR). The case has subsequently returned for readjudication. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU rating is part of an appeal for an increased rating claim when such claim is raised by the record. Here, the Board notes that the issue of unemployability has been raised both by the Veteran and the evidence of record. As such, the Board finds that the record raises a claim for TDIU. 1. The claim of entitlement to an initial rating in excess of 50 percent for service-connected PTSD The Veteran asserts that the severity of the symptoms associated with his PTSD warrant a rating in excess of 50 percent. Disability ratings are determined by application of a ratings schedule which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, pyramiding, which is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim 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). The Veteran's PTSD is rated under Diagnostic Code 9411, 38 C.F.R. § 4.130. Mental disorders are rated under the General Rating Formula for Mental Disorders pursuant to 38 C.F.R. § 4.130. A 50 percent rating is warranted for 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 rating is warranted when there is 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); and an inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 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, 442-43 (2002). However, 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, and that those symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. Turning to the facts of this case, the Veteran has a present diagnosis of PTSD for which he is in receipt of service connection. Post-service treatment records reflect intermittent treatment over the years with difficulties maintaining his prescribed medication regimen. In November 2012, a private report indicated that the Veteran experienced severe anxiety related to his PTSD. On evaluation, he exhibited good hygiene, logical thought, and fair judgment. He denied suicidal and homicidal ideation or plan. The Veteran underwent a February 2013 VA examination to assess the severity of his PTSD. He was recently terminated from his job due to anger problems. He reported feeling angry, sad, and like he wanted to kill people. He experienced road rage and nightmares. During the examination, he mumbled and used foul language. The examiner noted a history of arrest for battery, as well as indications of alcohol abuse from the record. The examiner concluded that the Veteran's present symptoms were anxiety and suspiciousness, but information was limited due to the Veteran's unwillingness to discuss his combat experiences in any detail and test results that were suggestive of malingering. In April 2013, VA treatment records reflect symptoms of anxiety and panic attacks associated with PTSD. He reported awakening in a panic, as well as experiencing panic attacks while working that caused him to feel that he needed to leave. He avoided triggers, such as military movies, and avoided discussion of his experiences in Iraq and Afghanistan. His clinician noted that his anxiety level interfered with his work and relationships. He appeared to have chronic depression and an irritable mood. In June 2013, the Veteran reported ongoing issues with nightmares, as well as acting out in his sleep, to include an incident of choking his girlfriend while asleep. He noted that he quit a job because he was having difficulty dealing with people. The Veteran presented to the appointment casually dressed and fully oriented. His mood was anxious and depressed with congruent affect. Speech was normal with no indication of perceptual disturbance or thought disorders. Insight and judgment were fair. His memory was intact, and he denied suicidal and homicidal ideation. In August 2013, the Veteran presented for treatment with good grooming and a cooperative behavior. He exhibited good eye contact, and he was fully oriented. The Veteran's speech was normal and suggested logical and organized thought form with non-bizarre thought content. His mood was anxious and depression with constricted affect. He denied suicidal and homicidal ideations. Memory was grossly intact with good insight, judgment, and impulse control. Around November 2013, the Veteran reported that he stopped his medication regimen as he did not want to be "needing" medications. As a result, his symptomatology worsened, and he noted that his sleep was more disturbed and interrupted. He felt more hypervigilant and anxious, as well as experienced difficulty concentrating. The Veteran's speech was normal, and he presented with an anxious mood and congruent affect. Attention, concentration, memory, and thought processes were normal on evaluation. There was no indication of auditory or visual hallucinations or delusional thoughts. Judgment was good, and he was fully oriented on examination. The Veteran continued to deny suicidal and homicidal ideation. In January 2014, the Veteran's girlfriend submitted a statement regarding his ongoing symptomatology. She reported that he drank alcohol to sleep. He needed to sit in certain places so that he could escape, if needed. The Veteran also looked at people in crows as if they might be out to get him. He exhibited anger and road rage issues, and he frequently thought debris in the street could be an improved explosive device (IED) while driving. He also reportedly experienced flashbacks, anxiety, and panic attacks. In May 2014, VA treatment records reflect an exacerbation in his symptoms due to stressors associated with a recent move. The new location had increased congestion and traffic, which aggravated the Veteran's history of driving in combat zones. As a result, he experienced marked distress while driving on the highway, and he reported a panic attack while driving the previous week. He exercised to alleviate symptoms, and he kept busy in school. He denied symptoms of mania, hypomania, and psychosis, as well as suicidal and homicidal ideation. The Veteran's alcohol consumption decreased to several per week. He reported to the appointment with adequate grooming and hygiene, and a calm, cooperative attitude. Cognitive function was grossly intact, and he was alert and oriented in all spheres. Speech was coherent and appropriate. Thought processes were linear and goal directed with normal content. He denied auditory or visual hallucinations. Insight and judgment were grossly intact. The Veteran underwent a second VA examination to assess his PTSD in July 2014. The examiner assessed overall occupational and social impairment with reduced reliability and productivity. The Veteran lived with his girlfriend and they shared a good relationship. He was a full-time student, but stayed at home when not in school as he did not trust anyone outside. He denied engaging in social activities, and reported no friends. He had been unemployed for one year as he had difficulty with others in the workplace. The Veteran reported poor sleep, nightmares, night sweats, avoidance of crowds or loud places, hypervigilance, road rage, mild paranoia, panic attacks, anxiety, and difficulty relaxing. The examiner noted that the Veteran's PTSD caused symptoms of anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The examiner noted that his symptoms impaired his performance and productivity at all levels of functioning, but did not find a total impairment overall. In October 2014, VA treatment records reflect ongoing depression and panic attacks. The Veteran denied manic episodes and psychosis, as well as suicidal and homicidal thoughts. He presented for the appointment with appropriate grooming and hygiene, and a calm, cooperative attitude. There were no delusions elicited, and he denied perceptual disturbances. In December 2014, the Veteran noted an improvement in his symptoms in the previous months. He continued to experience nightmares and sleep impairment, as well as anxiety and difficulty interacting with others at work. He continued to deny suicidal or homicidal ideation, plan, or intent. The Veteran was fully alert and oriented with casual dress on presentation. His speech was clear and coherent, and he exhibited an irritable mood with congruent affect. Thought processes and content were within normal limits. There were no perceptual disturbances. Judgment and memory were good. The Veteran then stopped attending his mental health appointments, and he did not report back until April 2015. He stopped as he "needed a break from everything," and the clinician noted that he was avoiding his trauma. The Veteran continued to experience anger while driving, but denied outbursts outside of driving. Exercise remained his primary coping mechanism. The Veteran appeared his stated age with casual dress and good grooming. There were no observable behavioral problems, and his attitude was cooperative and guarded. He remained fully oriented with normal speech and thought processes and content. He denied suicidal and homicidal ideation. The Veteran subsequently reengaged with treatment through VA, and his symptoms remained relatively consistent. He continued to experience anger and irritability while driving, though his panic attacks decreased. He continued to deny suicidal and homicidal ideation. The Veteran remained fully alert and oriented with good grooming in subsequent appointments. Around February 2016, the Veteran relocated again with his girlfriend. His mood was noted to be stable, and he remained unemployed but looking for work. In July 2016, the Veteran reported experiencing anxiety when he left the house. He also endorsed difficulties in his relationship with his girlfriend. In March 2017, the Veteran's family members submitted multiple statements about his ongoing symptoms. His parents reported that he experienced severe panic attacks, and could not be around crowds. A friend noted that he was not capable of caring for his children before his previous divorce, and he had problems driving due to mistaking objects in the road for IEDs. The Veteran's girlfriend noted that he continued to exhibit symptoms of road rage, anger, nightmares, depression, and anxiety. In August 2017, a treating clinician noted that the Veteran was "quite ambivalent" about engaging in treatment, and he declined psychotherapy. He was also noncompliant with psychotropic medications. He continued to deny psychosis, mania, and suicidal ideation. In January 2019, the Veteran underwent another VA examination to assess the severity of his condition. The examiner assessed occupational and social impairment with reduced reliability and productivity. The Veteran remarried in December 2017, but did not reside with his wife as they were experiencing "resentment" about "the way things have been going," They were bothered about habits and approaches that each had in the way they lived their lives. The Veteran cited disagreements with organization in the house, sleeping behaviors, and cleanliness. The Veteran, instead, lived with his parents and spent most of his time in his room. He had one close friend, his brother, but he did not trust people enough to establish other friendships. The examiner assessed symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. On examination, the Veteran's appearance and grooming were adequate. His speech was normal, and his attention was intact. He maintained appropriate eye contact during the examination. Affect was broad with a slightly depressed mood. Thought processes were linear, and he did not display any perceptional issues or psychotic features. The Veteran denied suicidal and homicidal ideation. In June 2019, a private clinician conducted an evaluation with the Veteran, to include a review of his treatment records. He noted that his symptoms had worsened since his discharge from service, and affected him both occupationally and socially. He was reportedly described as unpredictable, irritable, expressing inordinate anger, threatening, violent, and suicidal. He no longer participated in activities or socialized. In sum, the Veteran had a "pervasive" mental illness that caused him to be incapable of functioning in most areas of life. Concurrent VA treatment records continue to note feelings of anger and depression. The Veteran continued to deny suicidal and homicidal ideation. His nightmares decreased, and his sleep had improved. The Veteran continued to present for treatment fully alert and oriented with good hygiene and grooming. He also denied hallucinations and delusions. In January 2020, the Veteran underwent another VA examination to assess his PTSD. The examiner again assessed occupational and social impairment with reduced reliability and productivity. He still lived with his parents, but he maintained good contact with his stepdaughter and two children. He did not have friends, and instead liked to watch television at home. The examiner noted symptoms of depression, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The Veteran presented with fair grooming and casual dress. He was cooperative and established a good rapport with the examiner. Speech was within normal limits. He denied suicidal and homicidal ideation. Thought processes were within normal limits. Insight, judgment, and reasoning were intact. There was no evidence of perceptual disturbances, paranoia, or delusional thinking. He was fully oriented on examination, and conducted his activities of daily living independently. Subsequent VA treatment records reflect compliance with his mental health medication regimen with noted stability of symptoms. He remained fully alert and oriented with good grooming and hygiene. Memory was intact. Thought processes were normal. There were no auditory or visual hallucinations. After a thorough review of the medical and lay evidence of record, the Board finds that the Veteran is entitled to a 70 percent rating, but no higher, for his PTSD. The Board recognizes that the Veteran suffered from deficiencies attributable or exacerbated by his PTSD. The Board's determination of the appropriate degree of disability is a finding of fact. In applying the ratings schedule, the Board considers the severity, frequency, and duration of psychiatric symptoms to determine the appropriate disability evaluation. See, e.g., Brewer v. Snyder, No. 15-2800, 2017 U.S. App. Vet. Claims LEXIS 90, at 13 (Vet. App. Jan. 31, 2017); citing Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). While symptoms are listed under each category for evaluation, the particular symptoms are to be demonstrative of that overall level of severity, frequency, and duration. Mauerhan, 16 Vet. App. at 442. As such, the Board has considered the symptoms specific to the Veteran throughout the period on appeal, and determined the analogous evaluation pursuant to the ratings schedule in 38 C.F.R. § 4.130. When considering the severity, frequency and duration of the impairments as delineated in the 70 percent evaluation, the Board notes that the symptoms listed present a significant impediment to daily life. Symptoms such as obsessional rituals which interfere with routine activities, near-continuous panic or depression, and the inability to establish and maintain effective relationships, present obstacles to routine functioning on a daily basis. Personal hygiene and grooming are not limited to one particular sphere, but affect work, school, and family relations. Spatial disorientation and intermittently illogical speech are markedly severe symptoms associated with basic cognitive function and the ability to interact with the world. Suicidal ideation, in of itself, represents the impulse or desire to remove oneself from the world entirely. As exemplified by the symptoms listed in this category, the 70 percent evaluation is appropriate for deficiencies that harm most areas of life. Either symptoms are continuous, or near-continuous, or represent such a severity that routine daily functions are chronically impeded. In contrast, the evaluation for a 100 percent impairment includes symptomatology that presents a total impairment to daily functioning. Not only are the representative symptoms of the most severe possible from a psychiatric disorder, but they interfere with the ability to independently engage in activities of daily life. Persistent delusions or hallucinations, disorientation to time or place, and significant memory loss all prevent the person from routine engagement with the world. The ability to even maintain the most basic hygiene standards has been harmed by the severity or frequency of the associated symptomatology. When symptoms of a psychiatric disorder are so severe as to present a total impairment to occupational and social activity, then a 100 percent evaluation should be afforded. Throughout the period on appeal, the Veteran regularly endorsed symptoms of anxiety, anger, flashbacks, nightmares, and chronic sleep impairment. He reported remaining home as he was not comfortable going outside or being around crowds or loud noises. He had one good friend, his brother, but did not seek out other friendships as he could not trust people. The Veteran remarried during the period on appeal, and his relationship with his second wife was described as both good and strained, though he remarked that much of the stress of living together came after their wedding and involved routine activities in the home such as organization, cleaning, and sleeping patterns. Earlier in the appellate period, the Veteran reported experiencing panic attacks associated with driving as he frequently mistook objects in the road for IEDs. His panic attacks improved through the extensive period on appeal, particularly as he more consistently engaged in mental health treatment. Overall, the manifestations of his PTSD impacted most areas of his life, certainly professionally as he found it difficult to hold a job due to anger, anxiety, and difficulty interacting with others, but also in his social relationships as discussed above. The June 2019 private opinion even noted that the Veteran's PTSD interfered with most areas of functioning, to include basic social settings and any modern occupational environment. Previous VA examinations of record may have found only reduced reliability in both occupational and social settings, but the overall severity of the Veteran's symptoms, to include consideration of ongoing VA treatment records, reflects more serious manifestations. While certainly severe, symptoms related to the Veteran's service-connected PTSD in this timeframe do not rise to the level of a total occupational and social impairment for the purposes of 38 C.F.R. § 4.130. His impairments, while touching on many areas of his life, are not of such severity to interfere with routine functions necessary for daily life. The Veteran was consistently alert and oriented in all spheres, and maintained his grooming and hygiene. The Veteran's mental faculties remained intact throughout this period. He denied perceptual disturbances, and his memory was found to consistently be intact. He did not demonstrate grossly inappropriate behavior, or present a persistent danger of hurting himself or others. The Board notes that the June 2019 private opinion describes him as violent with a history of suicidal ideation. These specific symptoms are unsupported by the preponderance of the record spanning the period on appeal. The Veteran consistently denied suicidal and homicidal ideation to his treating clinicians, and he was not found to be of moderate or high risk of hurting himself or others with repeated assessments over time. The private clinician noted homicidal ideation from the February 2013 examination, but he does not address the examiner's conclusion that the Veteran's symptom presentation indicated malingering, and homicidal ideation was not formally documented as associated with his PTSD. The private clinician also states that he had an "outburst of anger and became violent" a few days before a July 1, 2016, VA appointment. This July 1, 2016, record, however, indicates that the Veteran reconnected with VA for treatment, and he had been experiencing anxiety, irritability, and poor sleep with weekly nightmares. He denied psychosis, mania, or suicidal ideation. The Veteran reported breaking a computer mouse a few days before the appointment. After further evaluation, the Veteran was found to not be a risk to himself or others even with his current symptomatology. Thus, the Board finds the June 2019 examination report's findings of violence are inconsistent with, and an overstatement of, those symptoms reported by the Veteran during his ongoing treatment through the previous decade, and thus are not probative to support a finding that the Veteran was a persistent danger of hurting himself or others. Overall, the Veteran's symptoms do not mirror the severity, frequency and duration of ones such as persistent delusions or hallucinations, or inability to attend to basic hygiene. He continues to perform the activities of daily living independently, including maintaining his hygiene and grooming. Resolving reasonable doubt in favor of the Veteran, manifestations of his PTSD throughout the period on appeal warrant a 70 percent initial rating. While the Veteran certainly continues to cope with severe symptoms, such do not rise to the level of a total occupational and social impairment as contemplated by the rating schedule, as discussed above. As the preponderance of the evidence weighs against the claim for an evaluation in excess of 70 percent, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. 2. The claim of entitlement to a TDIU Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). However, a total rating may nonetheless be granted on an extra-schedular basis in exceptional cases (and pursuant to specifically prescribed procedures) when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16 (b). In the present case, the Veteran is service-connected for PTSD (70 percent from November 15, 2012); sleep apnea (50 percent from October 25, 2017); degenerative joint disease of the right shoulder (10 percent from November 15, 2012, and 20 percent thereafter); a lumbosacral strain (10 percent from November 15, 2012, and 20 percent thereafter); a left wrist strain (noncompensable prior to December 3, 2018, and 10 percent thereafter); a right ankle strain (noncompensable prior to December 3, 2018, and 10 percent thereafter); a left ankle strain (noncompensable prior to December 3, 2018, and 10 percent thereafter); left leg shin splints (noncompensable prior to December 3, 2018, and 10 percent thereafter); and, right leg shin splints (noncompensable prior to December 3, 2018, and 10 percent thereafter). Overall, the Veteran meets the schedular criteria for TDIU throughout the period on appeal. The record reflects that the Veteran was self-employed as a contractor installing cable services. He also had a brief position as a package unloader, as well as positions as an electrician and delivery person. The Veteran had one year of college education. The evidence of record documents significant interference with the Veteran's employment caused by his service-connected disabilities. His PTSD rendered him largely unable to interact with others, as evinced by his frequent altercations with coworkers and anxiety while in the workplace. He experienced anxiety just leaving the house, and he has a history of panic attacks while driving due to visualizing IEDs in the road. While the Veteran attempted additional education following discharge, he found the programs overwhelming at times, causing him to drop out. The Veteran's ankles interfered with his ability to walk around repetitively in and out of vehicles. He also reported experiencing increased pain in his back while working as an unloading employee. The June 2019 private opinion noted that he would work best in an environment with minimal contact with coworkers and the general public. His ability to learn and complete simple tasks was not impaired, but his ability to understand and remember detailed instructions was mildly to moderately impaired. Unfortunately, the Veteran has experienced significant difficulty completing subsequent attempts at additional education. He reported going to school to become a pilot, but he did not finish that program. In April 2017, records note that he was enrolled in summer classes, but it is not clear if such were associated with a degree or training program. Based on the foregoing, and resolving all reasonable doubt in favor of the Veteran, the Board finds the service-connected disabilities have rendered the Veteran unable to maintain substantially gainful employment consistent with his education and occupational background throughout the period of the claim. The Veteran's reports of his occupational history are competent and consistent with additional information associated with the claims file. The Veteran's VA examinations and VA treatment records consistently reflect symptoms of social isolation and avoidance. He has consistently expressed difficulties interacting with other people. Instead, the Veteran's records reflect isolation and anxiety when he is away from home. VA examinations have consistently found symptoms including disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and an inability to establish and maintain effective relationships. The Veteran has consistently reported that interpersonal conflicts have caused him difficulty in maintaining jobs, and lead to periods of unemployment. (Continued on the next page) The Board acknowledges that the individual VA examiners have not found that his PTSD presents a total occupational and social impairment. However, the Board notes these opinions do not specifically address the level of the Veteran's functional impairment alone, nor do they consider his educational and occupational history. The Veteran has an occupational history of manual labor, which is hampered by his service-connected physical disabilities. There is no indication that he has the training or experience for a sedentary office position, and post-service attempts to gain additional training or educational degrees have been stymied by his PTSD symptoms. Additionally, the Veteran's PTSD causes significant impairments in his ability to interact with others, to include in the workplace. In sum, the Board is satisfied that the Veteran's service-connected disabilities have rendered the Veteran unable to maintain substantially gainful employment consistent with his education and occupational background. Accordingly, TDIU is warranted. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Fisher, 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.