Citation Nr: 21030512 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 12-16 751 DATE: May 19, 2021 ORDER Entitlement to a 70 percent rating for posttraumatic stress disorder (PTSD) from September 7, 2010 to June 20, 2011 is granted. Entitlement to a 70 percent rating for PTSD beginning September 1, 2011 is granted. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service-connected disabilities is granted. FINDINGS OF FACT 1. From September 7, 2010 to June 20, 2011, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas. 2. The Veteran is already in receipt of a temporary total rating from June 20, 2001, to August 31, 2011. 3. Beginning September 1, 2011, the Veteran's PTSD is manifested by occupational and social impairment with deficiencies in most areas. 4. The Veteran is shown to be unable to obtain or retain substantially gainful employment due to service-connected disabilities. CONCLUSIONS OF LAW 1. From September 7, 2010 to June 20, 2011, the criteria for a rating of 70 percent for PTSD have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.130 (Diagnostic Code 9411). 2. Beginning September 1, 2011, the criteria for a rating of 70 percent for PTSD have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.130 (Diagnostic Code 9411). 3. The criteria for a TDIU have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from May 1970 to May 1974. This matter comes before the Board of Veterans' Appeals (Board) from the February and December 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared at a June 2013 hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. This matter was previously before the Board in March 2021 and was remanded for the issuance of a Supplemental Statement of the Case (SSOC). In March 2021, an SSOC was issued. The Board therefore finds that there was substantial compliance with the prior remand order, as is discussed more fully below, and the Board may continue with its determination. Stegall v. West, 11 Vet. App. 268 (1998). INCREASED RATING The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating greater than 50 percent for the period between September 7, 2010 to June 20, 2011 and then again beginning September 1, 2011. The Board concludes that the Veteran's symptoms more closely approximated the symptoms associated with a 70 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 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; or memory loss for names of close relatives, own occupation or own name. 1. Entitlement to a rating greater than 50 percent for PTSD from September 7, 2010 to June 20, 2011 The Veteran contends that his service-connected PTSD warrants a rating higher than 50 percent from September 7, 2010 to June 20, 2011. In August 2010, the Veteran was diagnosed with PTSD and began receiving psychiatric care at a VA outpatient clinic. An August 2010 Vet Center assessment stated that the Veteran's PTSD symptoms included depression, isolation, alienation, avoidance of feelings, rage, anxiety, sleep disturbances, intrusive thoughts, startled responses, eating changes, loss of motivation, nightmares, memory problems, and irritability. In September 2010, the Veteran told his VA psychiatrist that he had low mood, anhedonia, social isolation, and irritability since he left Vietnam. He stated that he self-medicated with alcohol, but denied that PTSD and depression problems caused any other limitations on his ability to work. The Veteran had a visible tremor in his jaw when discussing emotional issues and his mood was noted as "not good." The Veteran denied suicidal or homicidal ideations. In an October 2010 Vet Center mental status evaluation, the Veteran's symptoms were noted to impact his sleep, involve anger, rage, frustration, memory problems, and focusing on tasks. The evaluation stated that the Veteran had disorganized thinking and sleep problems, and that he hears his name being called. However, although the Veteran was noted to be quite symptomatic, the treatment note indicated that his symptoms were improving. A November 2010 VA treatment record states that the Veteran reported thoughts of killing himself. In February 2011, the Veteran underwent a VA PTSD examination. The examiner noted that the Veteran was having chronic difficulties with mood, primarily irritability, poor sleep, sadness, and nightmares of his combat trauma. He admitted to rare thoughts of suicide without definite plan or intent to harm himself. It was also noted that the Veteran socially isolates himself, avoids crowds, has occasional panic attacks when in crowds or driving his car in heavy traffic, and suffers from chronic sleep impairment. The examiner reported that the Veteran has a good relationship with his family, although he is irritable at times. The examiner stated that the Veteran's thought process was logical with normal communication and associations were intact. The Veteran denied hallucinations, delusions, obsessions or compulsions, and homicidal intent. The examiner stated that the Veteran's affect was judged to be one of mild anxiety. The February 2011 examination noted that the Veteran's PTSD symptoms included nightmares, flashbacks, recurrent intrusive distressing recollections, avoidance of activities and situations that might arouse recollections of trauma, markedly diminished interest in significant activities, and feelings of detachment or estrangement from others. The examiner stated that the Veteran's PTSD causes definite impairment in functional status, qualify of life, and employment. Additionally, the examiner stated that the Veteran has chronic daily definite emotional symptoms with nightmares of combat trauma since leaving Vietnam. Contrary to VA treatment notes from February 2011 stating that he has had rare thoughts of suicide, in both March and May 2011, the Veteran denied ever having any thoughts about death or about killing himself. The Board finds that for the period of September 7, 2010 to June 20, 2011, the Veteran's PTSD most approximates a 70 percent rating as a result of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms comparable to suicidal ideation, near-continuous panic or depression, flattened affect, depression, impaired impulse control, difficulty in adapting to stressful and maintaining effect relationships, hypervigilance, flashbacks, and recurrent nightmares. VA and private treatment records, the February 2011 VA examination, and the Veteran's lay statements show that the Veteran's PTSD was manifested by symptoms associated with a 70 percent rating suicidal ideation, near-continuous panic, and difficulty in adapting to stressful circumstances, and symptoms associated with a 100 percent rating (delusions and hallucinations). He also had symptoms that are not listed with a specific rating, such as difficulty making decisions, isolation, crying spells, hypervigilance, and below average concentration. The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. Further, difficulty making decisions, isolation, crying spells, and below average concentration are similar to near-continuous panic or depression affecting the ability to function independently, which are contemplated by the assigned 70 percent rating. The Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 70 percent rating. The Veteran experienced occupational and social impairment with reduced reliability and productivity with deficiencies in most areas. Mental status examinations in VA and private treatment records and the February 2011 VA examination indicate that the Veteran had occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. However, the examiner stated that the Veteran has generally satisfactory functioning of routine behavior, self-care, and normal conversation. The Board notes that the Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Board acknowledges that the Veteran has stated that he has had thoughts of suicide. However, the Veteran has also denied thoughts, intent, or a plan involving self-harm in existing treatment records. Additionally, although there were rare complaints of suicidal ideation, a higher rating of 100 percent is not warranted as the Veteran did not have persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Further, it is not shown that he had total occupational and social impairment. In fact, the Veteran has maintained family relations. While the Veteran did experience symptoms contemplated by a 100 percent ratingdelusions and hallucinationsthe evidence overall does not demonstrate the level of impairment associated with a 100 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. While August 2010 VA treatment records show the Veteran reported perceived alienation and rage, prior and subsequent treatment records contain reports, including the Veteran's February 2011 VA examination, note the Veteran reported a good relationship with his family. While the Veteran believes that he is entitled to a higher rating on the basis of Global Assessment of Functioning (GAF) scores, "[a]n adjudicator is not permitted to rely on evidence that the American Psychiatric Association itself finds lacking in clarity and usefulness." Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. Therefore, for the period of September 7, 2010 to June 20, 2011, the Board finds that the Veteran's PTSD warrants a 70 percent rating, and no higher is warranted. 2. Entitlement to a rating greater than 50 percent for PTSD beginning September 1, 2011 The Veteran contends that his service-connected PTSD warrants a rating in excess of 50 percent beginning September 1, 2011. In September 2011, the Veteran's spouse submitted a statement in support of her husband's claim stating that the Veteran has mood swings, no patience, and yells frequently. She also stated that her husband has unexplained anger outbursts. The Veteran's stepson also submitted a statement stating that the Veteran appears to not be getting much sleep because of his nightmares and that he thinks that the Veteran's depression is worse. Additionally, the Veteran's brother-in-law submitted a statement on the Veteran's behalf stating that the Veteran is extremely impatient and has frequent anger outbursts (yelling), appears to be withdrawn from his family, and depressed. The Veteran's step-child also submitted a statement noting that the Veteran does not sleep, has nightmares, does not express his feelings, and believes that the Veteran's depression was getting worse. Since September 2011, the record contains evidence of impaired impulse control, such as unprovoked periods or irritability and violence (such as throwing items on the floor). Additionally, it is stated throughout the record that the Veteran reports a low mood and irritability. In December 2011, the Veteran underwent a VA PTSD examination. The examiner discussed that the Veteran also suffers from depressive disorder that is secondary to his PTSD. The examiner discussed that the Veteran has a depressed mood lasting more than half the day on an average of 3 days per week. Additionally, the Veteran experiences daily recurrent and intrusive distressing recollections of a traumatic event he experienced in Vietnam and has distressing dreams of this event an average of five times per week. The Veteran stated that he has difficulty staying asleep every night, irritability on a daily basis, and difficulty concentrating four to five times per week. Additionally, he reported being hypervigilant, avoiding activities, places, people, and emotions that arouse recollections of the traumatic event, markedly diminished interest in significant activities, and feelings of detachment from others. Although, the Veteran reported good relationships with his family, with whom he lives with. The Veteran's PTSD was manifested by depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran denied suicidal or homicidal thoughts, plans, or intent, did not evidence impairment in judgment, and evidenced an ability to maintain minimal personal hygiene. The examiner stated that the Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity. In a September 2012 Vet Center treatment note, the Veteran reported a less depressed mood overall with minimal depressive symptoms and improved sleep with half as many nightmares per week. In November 2012, the Veteran reported mild depressive symptoms and some improvement in agitation and irritability. He reported less moodiness and a decrease in symptoms. The Veteran reported using techniques to monitor negative thought processes which slightly decreased the amount of time spent thinking about past traumatic events. In an August 2015 VA treatment note, the Veteran reported that he is doing fairly well, has improved depression, and minimal sleep intrusion with nightmares (one to two times a month). The doctor stated that there is overall improvement and the Veteran was in "really good spirits." However, in January 2016, the Veteran reported that his nightmares were worse and the inability to be outside due to the weather increased his anxiety. In January 2016, 6he Veteran submitted an affidavit stating that his PTSD has caused him to have frequent sudden outbursts of irritability, anger, and mood swings. The Veteran stated that his irritability, anger, and mood swings have impacted his family and social relationships. Additionally, the veteran stated that he has difficulty handling stressful situations, experiences depression two to three times a week that results in isolation, has nightmares one to three times a week, and avoids crowds. Conversely, in February 2016 the Veteran stated that he is slightly more able to control his anger and has had only a few nightmares following days when he has had a particularly frustrating day. He stated that his mood was relatively good and has been engaged in leisure activities. The examiner stated that the Veteran's sleep is overall better. In June 2016, the Veteran reported improved irritability and that his nightmares were neither worse nor better. In January 2017, the Veteran underwent a VA PTSD examination. The examiner characterized the Veteran's PTSD as having occupational and social impairment with reduced reliability and productivity. The Veteran stated that not much has changed in his social or family life since his previous examination. He stated that he tolerates family gatherings for 60 to 90 minutes at a time and has been able to maintain a satisfactory relationship with his wife and other family members. The Veteran stated that he has no close friends and prefers to be alone and spends most of his time at home caring for their animals, doing leather work, and watching television. The Veteran told the examiner that he did not have any temper outbursts at work, and that his temper outbursts are essentially focused on his wife. The Veteran was able to recite the traumatic events he experienced in Vietnam in a matter of fact manner without any great stress. He stated that most of his problems have to do with nightmares and that he only sometimes experiences anxiety. The Veteran expressed worrying about upcoming VA appointments. Additionally, the Veteran reported the following PTSD symptoms: avoidance of talking about the stressors (however, this symptom has improved as he has been able to talk with his wife about the stressors in Vietnam), exaggerated startle response occurring monthly, avoidance of crowds, nightmares occurring 12 times a month, chronic sleep problems, detachment, and irritability occurring 4-5 times per week. The January 2017 examiner concluded his examination report by finding that the Veteran is not a credible historian regarding his mental health symptoms and problems. The examiner discussed that the Veteran has told inconsistent stories to Social Security, a private vocational evaluator, and the VA regarding sleep problems, leisure interests, severity of symptoms, and the impact of his mental health symptoms on his occasional functioning. The Board notes that the Veteran has claimed that the January 2017 examination is inadequate because the examiner made impermissible factual determinations regarding his credibility, based opinions on factually incorrect information, and provided flawed medical rationales. Therefore, pursuant to the Board's December 2018 remand, the Veteran underwent another PTSD examination in October 2019. That examiner stated that the Veteran's PTSD results in occupational and social impairment with reduced reliability and productivity. Additionally, the Veteran's PTSD was noted to manifest in the following symptoms: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, inability to establish and maintain effective relationships, suicidal ideation, and impaired impulse control, such as unprovoked irritability with period of violence. The Board finds that beginning September 1, 2011, the Veteran's PTSD most approximates a 70 percent rating as a result of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms comparable to suicidal ideation, near-continuous panic or depression, flattened affect, depression, impaired impulse control, difficulty in adapting to stressful and maintaining effect relationships, and recurrent nightmares. VA and private treatment records, the October 2019 VA examination, and the Veteran's lay statements show that the Veteran's PTSD was manifested by symptoms associated with a 70 percent rating, such as suicidal ideation, impaired impulse control, inability to establish and maintain effective relationships, and difficulty in adapting to stressful circumstances. Although there were rare complaints of suicidal ideation, a higher rating of 100 percent is not warranted as the Veteran did not have persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Further, it is not shown that he had total occupational and social impairment. In fact, the Veteran has maintained family relations. The Board notes that the Veteran has expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Board acknowledges that the Veteran has stated that he has had thoughts of suicide. However, the Veteran has also denied thoughts, intent, or a plan involving self-harm in existing treatment records. While the Veteran did experience symptoms contemplated by a 100 percent ratingsuicidal thoughts (persistent danger of hurting self)the evidence overall does not demonstrate the level of impairment associated with a 100 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. While September 2011 lay statements note that the Veteran has serious, frequent and unexplained anger outbursts, the Veteran's VA treatment records note that the Veteran's mood has improved over the years and his anger has decreased (as noted in an August 2016 VA treatment note). Additionally, in January 2016, the Veteran denied hallucinations or delusions and in May 2019, the Veteran denied anxiety, insomnia, psychosis, or suicidal/homicidal ideations. The Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 70 percent rating. The Veteran experienced occupational and social impairment with reduced reliability and productivity with deficiencies in most areas. Mental status examinations in VA and private treatment records and the October 2019 VA examination indicate that the Veteran had occupational and social impairment with reduced reliability and productivity. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating beginning September 1, 2011. Therefore, beginning September 1, 2011, the Board finds that the Veteran's PTSD warrants a 70 percent rating, and no higher. 3. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service-connected disabilities The Veteran contends that he is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is 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(a). It is the established policy of VA that all Veterans who are unable to secure or follow a substantially gainful occupation by reason of service connected disability or disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." See 38 C.F.R. §§ 3.340 (a)(1), 4.15. "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16(a). TDIU is precluded for any period of gainful employment, which is generally defined as annual earnings above the poverty threshold. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009) (proof of unemployment is necessary to raise a TDIU claim). Marginal employment is found whenever the Veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census as the poverty threshold for one person. However, 38 C.F.R. § 4.16 further provides an exception to the income limitation regarding employment in a protected environment, such as family business or sheltered workplace, on a facts found basis. Id. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to a TDIU is whether his or her service-connected disabilities, alone, are of sufficient severity to produce unemployability. Factors to be considered are the Veteran's "education, employment history and vocational attainment." See 38 C.F.R. § 4.16(b). As an initial matter, on the veteran's August 2016 application for TDIU, the Veteran stated that his highest level of education is a high school diploma and he last worked full time on November 1, 2010. The Veteran stated that he left his last job as a truck driver "in part, because of [his] PTSD symptoms." The Veteran reported that he became irritable and angry with the owner. During the Veteran's December 2011 VA examination, the examiner stated that the Veteran's PTSD and depressive disorder combined do not preclude his ability to maintain substantial, gainful employment. Instead, the examiner noted that these mental health disabilities only result in reduced reliability and productivity. Furthermore, the Veteran stated that his recurrent intrusive distressing recollections and dreams about the traumatic event he experienced in Vietnam occurred at about the same frequency and severity throughout his working career. In October 2016, the Veteran submitted a private vocational assessment in support of his argument for entitlement to a TDIU. The assessment stated that for half of each month, the Veteran is not able to do "anything much" because of emotional restrictions caused by his PTSD. On these days, the Veteran stated that he does not go far from his home. The assessment stated that because of the Veteran's inability to "do anything on a regular and consistent basis" he could not perform even "a simple job." The Veteran reported that his emotional disability would cause him to be absent from any job more often than an employer would tolerate. The assessment discussed the Veteran's VA examinations and VA treatment notes, similarly discussed above, and focused on the Veteran's depressed mood, nightmares, and anger issues. The assessment ultimately opined that the Veteran is precluded from securing and following a substantially gainful occupation due to his reduced reliability and productivity caused by his PTSD. Furthermore, the assessment stated that there are no jobs in the local or national economies that the Veteran can perform. However, in the Veteran's January 2017 VA examination report, the examiner stated that the Veteran denied that any mental health problems ever interfered significantly with his ability to work. In fact, the examiner opined that there are not many functional limitations that apply to the Veteran because of his mental health disabilities. The examiner stated that although the Veteran would work better mostly alone, the Veteran has demonstrated an ability to work with others for over 20 years even when his PTSD symptoms were present. Additionally, the examiner did not believe that the Veteran's sleep problems would cause any functional limitations and stated that the Veteran's descriptions of his irritability seem to be limited only to his wife and therefore would not result in any functional limitations in the workplace. The January 2017 examiner disagreed with the October 2016 vocational assessment and stated that the assessment appears to only look at problematic times in recent years and discounted the most recent psychiatric evaluations that indicate the Veteran's stability and improvement of PTSD and depression symptoms. At the Veteran's October 2019 VA examination, the examiner stated that the Veteran's indicated PTSD symptoms and predominantly depressed mood preclude his ability to function productivity in a work environment. The examiner went on to say that the Veteran's irritability, dislike, and distrust of other persons, lack of ability to respond effectively in a stressful situation, impaired judgment, and his discomfort in crowded places would make it very difficult for the Veteran to work in such conditions. Resolving all reasonable doubt in favor of the Veteran, based on the medical and lay evidence discussed throughout this decision, the Board finds that the evidence demonstrates that entitlement to a TDIU is warranted as the evidence of record shows that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service connected disabilities, primarily his PTSD. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mountford, 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.