Citation Nr: 21040744 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 15-10 720 DATE: July 6, 2021 ORDER A rating in excess of 50 percent prior to March 18, 2014, for post-traumatic stress disorder (PTSD) is denied. Subject to the laws and regulations governing the award of VA monetary benefits, a rating of 70 percent, but no more, from March 18, 2014, for PTSD is granted. A total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. Prior to March 18, 2014, the Veteran's PTSD consistently manifested in irritability, sleep difficulties, memory lapses, nightmares, mild anxiety, self-isolating behavior, hypervigilance, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, resulting in occupational and social impairment with reduced reliability and productivity. 2. From March 18, 2014, the Veteran's PTSD consistently manifested in irritability, sleep difficulties, memory lapses, nightmares, self-isolating behavior, hypervigilance, near-continuous panic or depression, impaired impulse control. difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, resulting in occupational and social impairment with deficiencies in most areas. 3. The Veteran's service-connected disabilities do not preclude him from obtaining and maintaining substantially gainful employment consistent with his level of education, prior work history and training. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent prior to March 18, 2014, for PTSD have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a rating of 70 percent, but no more, from March 18, 2014, for PTSD have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, DC 9411. 3. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5103(a), 5107(b); 38 C.F.R. §§ 3.341, 4.16, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1965 to January 1969 and from July 1974 to July 1978. These matters come before the Board on appeal from a July 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Thereafter, they were previously remanded by the Board in June 2018 for further evidentiary development. Substantial compliance with the remand requests having been accomplished, the Board may proceed to consider the claims. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating The Veteran was granted service connection for PTSD at 10 percent disabling, effective December 1, 2010, under 38 C.F.R. § 4.130, DC 9411, the General Rating Formula for Mental Disorders. Following the Veteran's appeal, the Agency of Original Jurisdiction (AOJ) increased the rating to 50 percent, effective December 1, 2010, in an October 2012 rating decision. The Veteran withdrew his appeal of the PTSD rating in November 2012. He submitted a claim for TDIU in November 2012 which incorporated an increased rating claim for PTSD. Following the June 2018 Board remand, the AOJ granted a 70 percent rating for PTSD, effective April 1, 2019, in an April 2020 rating decision. Accordingly, the Board will consider entitlement to a rating in excess of 50 percent for PTSD from the date of claim, November 6, 2012, to April 1, 2019, including whether there was a factually ascertainable increase in severity within the year preceding the increased rating claim. See 38 C.F.R. § 3.400(o)(2). The Board will also consider entitlement to a rating in excess of 70 percent for PTSD from April 1, 2019. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. Under 38 C.F.R. § 4.130, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where 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; 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 work-like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation is assignable where 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather 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, 443 (2002). Thus, the Board will consider whether "the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code," and, if so, the "equivalent rating will be assigned." Id. In Vazquez-Claudio v. Shinseki, the Federal Circuit held that a Veteran may only qualify for a given disability rating "by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." 713 F.3d 112, 117 (Fed. Cir. 2013) ("Reading [38 C.F.R. §§ 4.126 and 4.130] together, it is evident that the 'frequency, severity, and duration' of a Veteran's symptoms must play an important role in determining his disability level."). Turning to the evidence of record, in a November 2011 VA psychiatric treatment record, the Veteran endorsed difficulty recalling things in conversations, dizziness, and sleep difficulties as his main psychiatric concerns. He noted that he was attending a PTSD group at a Veteran Center, as well. Upon observation, appearance and motor activity were normal. The Veteran had an irritable mood with congruent affect. He described difficulty with memory but scored a 27 out of 30 on a miniature mental status examination. He was oriented on all spheres and speech and intelligence were normal. Insight was fair and judgment was abnormal. The Veteran had no delusions, compulsions, hallucinations, suicidal thoughts, and he was not a danger to others. He obsessed with his deteriorating ability to recall information. Prescribed Trazodone was increased in dosage and the Veteran was encouraged to keep attending group therapy. In January 2012, the Veteran stated that he had continued problems with word-finding and forgetfulness. His mood was anxious when unable to recall words or finish expressing thoughts, his affect demonstrated mild anxiety, and displayed some difficulty with word-finding. Insight and judgment were fair and he was obsessed with how he came across to others. A mental status evaluation was otherwise normal. He was referred for neuropsychological testing. The Veteran underwent neuropsychological testing in March 2012. He endorsed mental health symptoms of fragmented sleep, decreased concentration, and variable mood but mainly alert and hypersensitive. The Veteran reported positive enjoyment from exercise and church attendance. Upon observation, he had appropriate grooming and hygiene; eye contact was good; speech was appropriate; he had no word-finding difficulty; thought processes were well-organized and goal-directed; there was no evidence of delusions, hallucinations, suicidal ideation, or homicidal ideation; he was alert and oriented on most spheres; he was pleasant, cooperative, and socially appropriate during the interview. On formal neuropsychological evaluation, the Veteran performed within normal limits on tasks involving word level reading, acquired vocabulary knowledge, working memory/attention, confrontation naming, semantic verbal fluency, visual perception, verbal reasoning, nonverbal reasoning, speed of processing, mental flexibility, contextual verbal memory, and rote verbal memory. He showed some variability in visual memory, borderline delayed free recall, low average performance with recognition cues, and borderline performance on a phonemic verbal fluency test. The evaluation yielded only very limited and focal evidence of neurocognitive impairment. He did not lack cognitive abilities for independent living or independent decision-making but had mild observed weakness with novel organization and planning. Given that mild weakness, clinicians indicated that he might encounter high levels of stress during complex decision-making in stressful or emergency situations. Continued follow-up by VA primary care and psychiatric clinicians was suggested. VA psychiatric treatment records from April 2012, May 2012, June 2012, October 2012, and February 2013 reflected ongoing complaints of difficulty sleeping, irritability, self-isolating behavior, and impaired memory. Mental status evaluations reflected irritable and anxious mood with congruent affect and fair insight but were otherwise normal. The Veteran underwent a VA examination in June 2013. He presented as somewhat defensive and irritable and indicated that the examiner could not understand his symptoms or struggles. He stated he went to church and spent a lot of time exercising. He also had a "man cave" in which he spent time. He was married for 16 or 17 years but felt that they were not compatible. They each had children from previous marriages and he spent time separately with his children. The Veteran stated he was close to his sister and his biological daughter. He enjoyed spending time with his grandchildren, as well. He was considering leaving his wife and living with his sister and his daughter instead. He also maintained relationships with his stepchildren. He engaged in many physical activities (tinkering around the house, swimming, roller skating, lifting weights, working out) and socialized with others at the gym and skating. The Veteran denied any missed time from work, disciplinary actions, or difficulties with productivity due to PTSD symptoms when he was employed. He attributed challenges to his work setting and interpersonal difficulties. He was more successful when working in an isolated environment. The Veteran was currently on Mirtazapine and continued to attend group counseling at the Veteran Center which reportedly helped him. The examiner indicated that the Veteran's symptoms associated with PTSD included anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The Veteran also described variable mood, memory difficulties, intrusive thoughts and nightmares, avoidance, isolating behavior, irritability, and hypervigilance. He slept with a loaded gun under his pillow but denied suicidal ideation, plan, or intent. The examiner determined that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. The examiner stated that the Veteran's mental health concerns were moderate in severity and resulted in mild functional impairment. He maintained some meaningful relationships, however, he felt disconnected from most people. He did continue to engage in some enjoyable leisure activities. Although not working for several years, he did report some history of job loss and reprimands due to his irritability. However, by his own report, he was largely successful at jobs that allowed him a degree of isolation. The examiner stated that it was less likely than not that the Veteran's PTSD rendered him unable to maintain substantially gainful employment. In August 2013, the Veteran told VA clinicians that he was no longer exercising anymore due to his bilateral lower extremity peripheral neuropathy. His Mirtazapine was also not as effective anymore. He was more hypervigilant in his home at night, as well. Private records of psychiatric treatment from December 2014 to November 2015 were obtained which reflected reports of panic attacks in traffic, sleep difficulties, nightmares, night sweats, relationship difficulties, isolating behavior, irritability, paranoia, and frustration. The Veteran reported that when he was working, he had to work alone and could not work with others because he became too aggressive. He worked out regularly to clear his mind. The Veteran's private treating clinician completed a PTSD Disability Benefits Questionnaire (DBQ) in January 2015. He diagnosed PTSD due to service with symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability establish and maintain effective relationships, impaired impulse control, persistent delusions or hallucinations, persistent danger of hurting self or others, disorientation to time or place, greatly disturbed sleep, recurring nightmares, irritability, reexperiencing, avoidance and isolating behavior, and great despair. The clinician determined that this resulted in occupational and social impairment with reduced reliability and productivity. The private clinician submitted another DBQ in October 2015. He diagnosed PTSD due to service with symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, flattened affect, difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability establish and maintain effective relationships, suicidal ideation, impaired impulse control, persistent delusions or hallucinations, persistent danger of hurting self or others, disorientation to time or place, greatly disturbed sleep, recurring nightmares, irritability, reexperiencing, avoidance and isolating behavior, and great despair. The clinician determined that this resulted in occupational and social impairment with deficiencies in most areas. The Veteran also underwent a VA PTSD examination in October 2015. He described living together with his wife of 20 years but having relationship difficulties. He maintained contact with his 4 adult children, as well. He did not have any close relationships but did socialize with an elderly neighbor, played basketball, and attended church. He also engaged in swimming, shooting, and skating, but did not interact with others during those activities. Although not employed, he did occasionally help out at a food pantry, assist an elderly neighbor with chores on a regular basis, and handled grocery shopping for his household. Based on his community functioning, the examiner determined that the prior VA examiner's conclusions about employability were still applicable. He was previously able to work in jobs that were largely solitary in nature where his irritability was not an issue. He described similar functioning when doing tasks for his neighbors and at church which did not involve extensive interpersonal interactions. The examiner discussed the private DBQs, noting that the severity of impairment noted by the private clinician was not consistent with the functioning described by the Veteran at the examination. The Veteran experienced suicidal ideation earlier in life but not currently. He also denied homicidal ideation. Upon observation, he was alert and fully oriented, appropriately groomed, cooperative, slightly irritable, and affect was somewhat constricted. His thoughts were organized and responses were relevant, he was an adequate historian, and there were no indications of significant limitations in memory or cognitive functioning. The examiner determined symptoms associated with the Veteran's PTSD included suspiciousness, chronic sleep impairment, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. The examiner determined that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. A September 2018 VA treatment record reflected that the Veteran's PTSD was stable and that he had stopped taking his prescribed psychiatric medications (Mirtazapine and Aripiprazole) and declined further VA mental health treatment. In December 2018, he reported difficulties with PTSD to VA clinicians, but stated that he was reluctant to have VA treatment and also did not want to take medication due to side effects. He denied suicidal and homicidal ideation. The Veteran underwent another VA PTSD examination in April 2019. He noted that he continued to reside with his wife but had relationship difficulties. He had 4 adult children with whom he had "decent" relationships. He continued to engage in swimming regularly and would make conversation with others around that activity. He had been less involved with his church due to family responsibilities. He was able to engage in the activities of daily living, including working around the house and doing household chores. He did sometimes forget to pay bills. He had assisted in caregiving for his mother-in-law while she was in hospice, as well. During previous employment, he got into trouble after reacting angrily to another employee. During that time, numerous health concerns also began to plague him. He voiced a high level of stress and frustration related to his need to provide financially for his family. When asked what he felt rendered him unemployable, he described anger and irritability with coworkers. The examiner discussed the prior VA examinations and the private DBQs. He stated that the signs and symptoms noted in the DBQs were inconsistent with the Veteran's self-report and presentation at that day's examination and with his VA medical record. The private clinician also did not provide supporting information with frequency, severity, or origins of noted symptoms. Based on those inconsistencies, the examiner stated that the information in the October 2015 DBQ should be regarded with caution. Upon observation, the Veteran was casually and appropriately dressed with appropriate hygiene and grooming; he was somewhat agitated and appeared distrustful; he was fully oriented; his mood was euthymic and affect was consistently agitated; even when joking or making light of a situation, he did not reciprocate positive emotional reactions; attention and concentration were adequate; speech was normal; eye contact was appropriate; thought content was free of any delusions and there was no evidence of a formal thought disorder; he exhibited good insight into his symptoms and the impact that they had upon his day-today functioning; and he did not exhibit nor voice any signs of impaired judgment or impaired abstract thinking. Regarding several PTSD criteria, the Veteran endorsed intrusive thoughts and memories related to his in-service traumatic experiences "all the time" and emotional reactivity to trauma triggers. He had nightmares about in-service trauma 4 to 5 times a month, with increased frequency at times of the year. He avoided triggers including watching movies about war. His self-report and presentation were reflective of a pervasive and persistent negative emotional state characterized by both anger and guilt. He described ongoing bitterness and anger directed towards VA and the military. He also endorsed feelings of feeling distant and cut-off from others and difficulty feeling empathic with regard to others' mistakes and actions. The Veteran described sleep difficulties, irritability, and anger outbursts. He sometimes shouted at his wife but not very frequently and had never had physical confrontations with her. His self-report was reflective of ongoing hypervigilance and concerns about safety. He stated that he had guns everywhere around his house and that he went shooting from time to time. He noted that he slept with a pistol under his pillow but kept the safety on. The Veteran stated that going swimming kept him grounded and evened out his mood and that he had positive levels of both interest and motivation. The Veteran was queried about psychotic symptomology as noted in the private DBQs. He flatly denied hallucinatory experiences and was oriented to time and place. He described some recent memory lapses but did not clearly report symptoms or concerns consistent with impairment of short and long-term memory. He flatly denied current suicidal ideation, plan, or intent and denied a lifetime history of suicide attempts or psychiatric hospitalizations. The Veteran was afraid that he might become so angry and have a "snap" reaction, leading him to harm someone, but in spite of that worry, he had not recently engaged in physical violence or aggression. The examiner stated that the private clinician's listing of persistent danger of hurting self or others, suicidal ideation, and impaired impulse control were not consistent with the Veteran's self-report at the examination. The examiner determined that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas. His ability to understand and follow instructions and his ability to retain instructions as well as sustain concentration to perform simple tasks did not appear to be impaired. His ability to respond appropriately to coworkers, supervisors, or the general public; his ability to accept supervision; his ability to be flexible in the work setting; and his ability for impulse control were considered moderately impaired. His ability to accept criticism and to work in groups were considered markedly impaired. The Veteran's irritability and history of workplace anger outbursts would likely interfere with his being successful in a workplace setting that involved frequent interaction with customers or the public, or a work setting that involved a good deal of interaction with coworkers and supervisors. VA treatment records from January 2020 reflected the Veteran's ongoing issues with PTSD including nightmares, agitation, and anger, but no new risk factors and no suicidal or homicidal ideation. In February 2020, the Veteran's wife reported that the Veteran had increasing memory lapses and impaired short-term memory, poor concentration, and nightmares in which he shouted in his sleep or attacked her on occasion. 1. A rating in excess of 50 percent prior to March 18, 2014, for PTSD, is denied. The Board finds that the Veteran's PTSD does not warrant a rating in excess of 50 percent prior to March 18, 2014. Prior to March 18, 2014, the Veteran's PTSD consistently manifested in irritability, sleep difficulties, memory lapses, nightmares, mild anxiety, self-isolating behavior, hypervigilance, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The Board finds that this symptom presentation did not result in occupational and social impairment with deficiencies in most areas. He was able to maintain several relationships (close relationships with his wife, children, and grandchildren and casual relationships with church members and others), engaged in many physical activities, and managed the activities of daily living. He dealt with increased stress or irritability by self-isolating and swimming. Prior to March 18, 2014, there was no evidence of suicidal ideation; obsessional rituals which interfered 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; or inability to establish and maintain effective relationships, or symptoms of a similar severity resulting in impairment with deficiencies in most areas. The Veteran endorsed and demonstrated irritability on occasion, but also demonstrated impulse control, specifically isolating himself and engaging in relaxing physical activities to manage his symptoms. He had difficulty adapting to stressful circumstances, but not such that he was impaired in most areas. As such, a rating in excess of 50 percent prior to March 18, 2014, is not warranted. 2. A rating of 70 percent, but no more, for PTSD from March 18, 2014, is granted. The Board finds that a 70 percent rating for PTSD is warranted from March 18, 2014. A VA treatment record of that date reflected the Veteran's new report of paranoia and of not leaving his home other than for medical appointments. The treating clinician indicated that he had paranoid delusions, an obsession with isolation, and compulsions involving the safety of himself in his home, carrying a gun and knife with him when he was alone. He was started on an antipsychotic medication, as well. The Board finds that this additional symptomology and required treatment represents a worsening in the Veteran's PTSD. Subsequent evidence that the Veteran frequently awoke holding his pistol, experienced panic attacks, and felt that he might "snap" and hurt others support a worsening of his disability. Although the October 2015 VA examiner found that the Veteran's PTSD only resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the evidence does demonstrate a variability in his symptom severity, frequency, and duration, particularly at different time of the year, with different familial stresses, and with varying medication compliance. As such, the Board has afforded the Veteran the benefit of the doubt and determined that from March 18, 2014, his PTSD manifested in occupational and social impairment with deficiencies in most areas, warranting a 70 percent evaluation. A rating in excess of 70 percent is not warranted at any point. The Veteran's PTSD did not manifest in 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, or symptoms of similar severity demonstrating total occupational and social impairment. Although the private clinician indicated that the Veteran had symptoms of persistent delusions or hallucinations, persistent danger of hurting self or others, disorientation to time or place, and impaired judgment and abstract thinking, there is no evidence of such symptomology in the clinician's own treatment records of the Veteran or VA treatment records. Both the October 2015 and April 2019 VA examiners determined that these reported symptoms in the DBQ were inconsistent with the medical evidence of record and the Veteran's presentation. Indeed, at the April 2019 examination, the Veteran himself flatly denied such symptomology. The Board attaches more probative value to the VA and private treatment records, the VA examinations, and the Veteran's own statements than the checked boxes on the DBQs. Accordingly, a rating in excess of 70 percent is not warranted. Further, the Board finds that the Veteran's disability is fully capable of evaluation under the rating schedule. There is no applicable provision that would warrant a higher rating in this case. TDIU The Veteran has contended that his service-connected disabilities have rendered him unemployable. A total disability rating for compensation purposes may be assigned where the schedular rating is less than total and where it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a 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). 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 or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 4.16, 4.19 (2016); see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). To meet the requirement of "one 60 percent disability" or "one 40 percent disability," the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment may also be held to exist, on a facts-found basis (including, but not limited to, employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16. The term "substantially gainful occupation" is not defined in the rating schedule. Rather, the Court in Ray v. Wilkie, found the phrase has two components: an economic one and a noneconomic one. 31 Vet. App. 58 (2019). In assessing the Veteran's ability to secure and follow a substantially gainful occupation, the Board is to consider the Veteran's history, education, skill, and training as well as physical abilities and mental abilities required by the occupation at issue. Id. Such specific physical ability factors include lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory, and visual. Id. Specific mental ability factors include memory, concentration, ability to adapt to change, handle workplace stress, getting along with coworkers, and demonstrating reliability and productivity. Id. From the date of claim, November 6, 2012, the Veteran's service-connected disabilities included PTSD rated 50 percent; diabetes mellitus type II rated 20 percent; tinnitus rated 10 percent; acanthosis nigrans rated 10 percent; and bilateral hearing loss, bilateral cataracts, and erectile dysfunction at noncompensable rates, resulting in a combined evaluation of 70 percent. From March 18, 2014, (per this decision), the Veteran's service-connected disabilities included PTSD rated 70 percent; diabetes mellitus type II rated 20 percent; tinnitus rated 10 percent; acanthosis nigrans rated 10 percent; and bilateral hearing loss, bilateral cataracts, and erectile dysfunction at noncompensable rates, resulting in a combined evaluation of 80 percent. The Veteran was service connected for peripheral neuropathy of the left lower extremity at 10 percent and peripheral neuropathy of the right lower extremity at 10 percent, effective December 8, 2014, still resulting in a combined evaluation of 80 percent. From August 20, 2020, the Veteran's service-connected disabilities included PTSD rated 70 percent; diabetes mellitus type II rated 20 percent; peripheral neuropathy of the left upper extremity rated 20 percent; peripheral neuropathy of the right upper extremity rated 20 percent; tinnitus rated 10 percent; acanthosis nigrans rated 10 percent; peripheral neuropathy of the left lower extremity rated 10 percent; peripheral neuropathy of the right lower extremity rated 10 percent; and bilateral hearing loss, bilateral cataracts, and erectile dysfunction at noncompensable rates, resulting in a combined evaluation of 90 percent. Accordingly, the Veteran's service-connected disabilities have met the threshold requirements for TDIU throughout the entire appeal period. In consideration of the "economic component," the Veteran has a high school education and an associate degree in electronic engineering. His military occupational specialties were vehicle mechanic, truck mechanic, and strategic maintenance system repairman. Post-service, he worked at several oil refineries. However, he was reportedly fired from two positions due to verbal aggression and difficulties getting along with coworkers. He was thereafter employed at an electronics company as an operator and then in maintenance. He noted that when he was allowed to work on his own or isolate himself, he was able to function well at his job. He was laid off from the electronics company in January 2008. His employer confirmed that he was terminated due to a reduction in force. He worked a "couple of jobs" after being laid off including telemarketing but disliked the position due to the large amount of oversight and the perceived pushiness of the superiors. He decided to leave that position. Subsequently, the Veteran considered himself "retired" and occasionally engaged in volunteer work, including helping at his church's food pantry and assisting an elderly neighbor with household chores. He later helped with caregiving for his mother-in-law. In consideration of the "noneconomic component," the Veteran has undergone multiple VA examinations to determine the functional impact of his service-connected disabilities. Regarding his PTSD, at a June 2013 VA examination, the Veteran reported that he succeeded at his prior positions when he was off by himself, working in a solitary environment. Otherwise, he experienced irritability and anger outbursts at coworkers. The examiner determined that his PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The examiner also concluded that it was less likely than not that his current symptoms rendered him unable to secure or maintain substantially gainful employment. He had difficulties in the past due to irritability and anger outbursts but did quite well at jobs that were solitary in nature. If the Veteran were able to secure a similarly isolative position befitting his skills and experience, it seemed likely that he could again be employed. A January 2015 private DBQ reflected the clinician's determination that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. Another DBQ submitted in October 2015 noted that his PTSD resulted in occupational and social impairment in most areas. An October 2015 VA examiner stated that based on the Veteran's community functioning (volunteering, church, and engaging in physical activities), he was able to participate in occupational activities that were isolated or that did not involve extensive interpersonal interactions. The examiner agreed with the June 2013 examiner's conclusion that he could be successful at jobs that allowed him a degree of isolation. It was determined that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. An April 2019 VA examiner asked the Veteran what he felt rendered him unemployable and he indicated that he had impatience with incompetence and would become angry and throw things. The examiner determined that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas. His ability to understand and follow instructions and his ability to retain instructions as well as sustain concentration to perform simple tasks did not appear to be impaired. His ability to respond appropriately to coworkers, supervisors, or the general public; his ability to accept supervision; his ability to be flexible in the work setting; and his ability for impulse control were considered moderately impaired. His ability to accept criticism and to work in groups were considered markedly impaired. The Veteran's irritability and history of workplace anger outbursts would likely interfere with his being successful in a workplace setting that involved frequent interaction with customers or the public, or a work setting that involved a good deal of interaction with coworkers and supervisors. Regarding the Veteran's diabetes mellitus, a June 2013 VA examiner determined that there was no functional impact from the disability. It was noted that the Veteran went to the gym, swam laps, and exercised 6 days a week for better glucose control. September 2015 and August 2020 examiners found that there was no functional impact from his diabetes mellitus. The August 2020 examiner also determined that there would be no restrictions for job activities required from his diabetes mellitus. Regarding the Veteran's peripheral neuropathy, a March 2015 VA examiner concluded that the condition prohibited prolonged walking. A September 2015 examiner found that peripheral neuropathy would make the Veteran unable to engage in occupations requiring prolonged standing or ambulation. An August 2020 examiner stated that there were no functional impacts and no restrictions for job activities required from peripheral neuropathy. Regarding the Veteran's bilateral hearing loss and tinnitus, it was noted in a March 2015 VA examination that tinnitus contributed to his not sleeping well at night. The Veteran reported to the examiner that his service-connected bilateral hearing loss made it difficult to hear his wife. An August 2020 VA examiner noted that the Veteran required family and friends to repeat themselves and his tinnitus woke him up and annoyed him. The examiner stated that with proper hearing and/or adaptive devices, he had no work restrictions due to hearing loss or tinnitus. Regarding the Veteran's cataracts, an August 2020 examiner found that there were no functional impacts. The examiner noted that the Veteran had some visual impairment but not enough to prohibit him from working. They were not severe enough for surgery and therefore did not impair his ability to perform normal daily functions such as work. Regarding the Veteran's acanthosis nigrans of the posterior neck, an August 2020 examiner found that there were no functional impacts and no restrictions for job activities required from the disability. Regarding the Veteran's erectile dysfunction, June 2013 and September 2015 VA examiners determined that there was no functional impact from the disability. An August 2020 examiner stated that there were no functional impacts and no restrictions for job activities required from erectile dysfunction. 3. A TDIU is denied. From an economic perspective, the Veteran has the education, skills, work history, and vocational training to perform work such as vehicle mechanics, electrical maintenance and operations, and telemarketing. From a non-economic perspective, his service-connected disabilities limit the ability engage in prolonged walking and standing, cause some difficulties with hearing, and would limit his ability to significantly engage with coworkers, customers, or clients. In Withers v. Wilkie, the Court noted that VA has not explicitly defined the meaning of "sedentary employment." Withers v. Wilkie, 30 Vet. App. 139 (2018). Until VA provides such a definition, "the meaning and relevance of the term will have to be discerned on a case-by-case basis from the medical and lay evidence presented and in light of each veteran's education, training, and work history." Id. at 149-150. The Board considered the physical ability factors noted in Ray, to include lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory, and visual. See Ray v. Wilkie, 31 Vet. App. at 58. The evidence suggests that the Veteran could not perform electrical maintenance and operations positions requiring prolonged walking and standing. However, there is no indication that he would not be able to engage in electrical maintenance and operations that did not require prolonged walking and standing and which is performed largely in a seated position. The Board also considered the mental ability factors noted in Ray, to include memory, concentration, ability to adapt to change, handle workplace stress, getting along with coworkers, and demonstrating reliability and productivity. See Ray v. Wilkie, 31 Vet. App. at 58. The Veteran himself has described difficulty interacting with coworkers as the main occupational limitation resulting from his service-connected PTSD. However, he also has indicated that when he was left to work on his own, he was able to complete his work duties without problems. As such, the evidence suggests that the Veteran would not be able to engage in occupations requiring significant interaction with others. Therefore, sedentary occupations he would be capable of performing based on his work history would include those that do not require frequent interaction with others, such as electrical repair and maintenance that could be accomplished by the Veteran working alone while seated. Based on the foregoing, the Board finds that the Veteran is not precluded from engaging in substantially gainful employment by reason of his service-connected disabilities alone. Given his education, skills, work history, and training, while his service-connected disabilities cause impairment, the evidence does not show the disabilities would preclude all such suitable work. The Board does not doubt that the Veteran's service-connected disabilities cause impairing symptomatology. This impairment of function is recognized by the ratings assigned to each of his service-connected disabilities. The evidence does not support that these disabilities preclude substantially gainful employment, specifically to include sedentary employment as outlined above. Additionally, the Veteran has other impairing nonservice-connected disabilities and is of advanced age. As noted above, consideration cannot be given to the impairing effects of nonservice-connected disabilities or advanced age. In light of the Veteran's past work history, training, and skills and in light of the medical evidence in this case, the Board finds the Veteran is capable of substantially gainful work. Accordingly, entitlement to TDIU is not warranted. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Rachel E. Jensen, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.