Citation Nr: 21041209 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 17-48 800 DATE: July 8, 2021 ORDER Entitlement to service connection for hypertension (also claimed as high blood pressure) as secondary to service-connected posttraumatic stress disorder (PTSD) and depression, Not Otherwise Specified (NOS) is denied. Entitlement to service connection for obstructive sleep apnea as secondary to service-connected PTSD and depression, NOS is denied. Entitlement to an evaluation in excess of 70 percent disabling for service-connected PTSD and depression, NOS (to include claimed insomnia) is granted. Entitlement to a total disability evaluation based upon individual unemployability is granted. FINDINGS OF FACT 1. The Veteran's hypertension (also claimed as high blood pressure) is not secondary to service-connected PTSD and depression, NOS, and is not otherwise related to an in-service injury, event, or disease. 2. The Veteran's obstructive sleep apnea is not secondary to service-connected PTSD and depression, NOS, and is not otherwise related to an in-service injury, event, or disease. 3. Throughout the appeal period, the severity, frequency, and duration of the Veteran's service-connected PTSD and depression, NOS has been manifested by symptomology consistent with total occupational and social impairment. 4. Resolving all doubt in the Veteran's favor, the evidence supports a finding that his service-connected disabilities have rendered him incapable of securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for hypertension (also claimed as high blood pressure) as secondary to service-connected PTSD and depression, NOS have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 2. The criteria for establishing entitlement to service connection for obstructive sleep apnea as secondary to service-connected PTSD and depression, NOS have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 3. The criteria for establishing entitlement to an evaluation in excess of 70 percent disabling for service-connected PTSD and depression, NOS (to include claimed insomnia) have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2020). 4. The criteria for establishing entitlement to a total disability evaluation based upon individual unemployability have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 3.102, 3.340, 3.341, 4.3, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty service with the United States Army from October 1975 to March 1982 and under honorable conditions from March 1982 to April 1983. In a September 2017 substantive appeal, the Veteran requested a video conference hearing. In July 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the claims file. Duty to Assist and to Notify VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2020). Copies of compliant VCAA notices were located in the claim's file. VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303 (a), 3.304 (2020). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical 'nexus' requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2020). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2020). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. The Board notes that it has thoroughly reviewed the record in conjunction with this case. 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 submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that 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 claimant). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue. 1. Entitlement to service connection for hypertension (also claimed as high blood pressure) as secondary to service-connected PTSD and depression, NOS The Veteran contends that he is entitled to service connection for hypertension as secondary to his service-connected PTSD and depression, NOS. For the reasons stated more fully below, the Board finds that the preponderance of the evidence is against his claim. In analyzing the Veteran's claim, the threshold inquiry before the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. On review of the record, the Board concludes that while the Veteran has a current diagnosis of hypertension, the preponderance of the evidence weighs against finding that the condition is causally related to active service, to include as secondary to service-connected PTSD and depression, NOS. Service treatment records are largely silent for any evidence of elevated blood pressures or a current diagnosis of hypertension. At enlistment, a report of medical examination revealed normal findings. No disqualifying defects were identified. In a corresponding report of medical history, the Veteran stated that he was in good health. Negative responses were recorded for inquiries regarding sleep trouble and high or low blood pressure. In June 1982, a subsequent report of medical examination made no reference to a current diagnosis of hypertension or obstructive sleep apnea. However, the Veteran's blood pressure was listed as 132/82. In October 1978, the Veteran's BP was listed as 112/70, and one year later, in April 1979, it was 118/82. At separation, a report of medical examination was silent for a current diagnosis of hypertension or obstructive sleep apnea in April 1983. In a corresponding report of medical history, the Veteran reported "feeling poorly." Although no complaints of high or low blood pressure were reported, he acknowledged trouble sleeping. Post-service treatment records show that the Veteran was diagnosed with hypertension, on or about April 2009. An elevated blood pressure without a diagnosis was listed in December 2010. Other treatment records listed a current diagnosis of hypertension in May 2011 and benign essential hypertension in February 2017. On examination in March 2017, a current diagnosis of hypertension was confirmed. The Veteran denied any chronic symptoms related to his hypertension. To treat his condition, oral medication Metoprolol was prescribed twice daily. An average blood pressure of 137/87 was noted after multiple tests in March 2017. No functional impairments were identified. Following the clinical evaluation, the examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran's hypertension proximately due to or secondarily related to his service-connected psychiatric condition. In support of the stated conclusion, the examiner acknowledged a review of research-based medical literature. No "direct and irrefutable" nexus of causation was found to support a linkage between PTSD and the development of essential hypertension. Moreover, a review of the Veteran's treatment records show that his diagnosis of essential hypertension predated his diagnosis of PTSD. Therefore, a secondary linkage could not be established. In July 2020, the Veteran testified at a Board hearing. Therein, he suggested that symptoms related to his service-connected PTSD caused his hypertension to worsen. Specifically, he reports feeling increasing stress and anxiety which caused elevations in his blood pressure. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. Generally, the Veteran is presumed competent to report on the onset of current symptoms, their impact on daily living and employment, and such reporting is deemed credible. However, as to the etiology of a particular claimed disability, the issue of causation of a medical condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In the instant case, there is no evidence that Veteran possesses the required training to diagnose hypertension or opine as to its etiology, to include on a secondary basis. To the extent his statements may be competent, the Board ultimately assigns greater probative weight to the medical evidence of record, to include opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. In this case, the Board observes that only a single elevated blood pressure was noted in service in June 1982. Post-service treatment records document a current diagnosis on or about April 2009, more than a decade after separation. Oral medications were prescribed to treat his condition. On examination in March 2017, a VA examiner considered the possibility of an etiological linkage between the Veteran's service-connected psychiatric condition and his hypertension. In rendering a negative etiological opinion, the examiner noted that his diagnosis of essential hypertension predated the initial diagnosis of PTSD. While the Board does not doubt that the Veteran experiences elevated blood pressures during periods of heighted anxiety, standing alone, this is insufficient to establish an etiological linkage between his hypertension and his service-connected PTSD. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for hypertension must be denied. 2. Entitlement to service connection for obstructive sleep apnea as secondary to service-connected PTSD and depression, NOS The Veteran contends that he is entitled to service connection for obstructive sleep apnea. However, as discussed in more detail below, the preponderance of the evidence is against his claim. In analyzing the Veterans' claim, the threshold inquiry before the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. On review of the record, the Board concludes that while the Veteran has a current diagnosis of obstructive sleep apnea, the preponderance of the evidence weighs against finding that his condition is causally related to active service, to include as secondary to service-connected PTSD and depression, NOS. As a preliminary matter, the Board incorporates by reference, the procedural history noted in Section 1. Post-service treatment records show that in June 2009, VA treatment records noted a suspicion of mild obstructive sleep apnea and a sleep study was recommended. In January 2011, an ear nose and throat (ENT) consultation noted a history of nasal fractures due to past trauma. A physical examination revealed adequate airway pressure. In April 2011, a neurology follow-up indicated that the Veteran refused a polysomnogram. However, an electromyography (EEG) study revealed normal findings. In February 2017, the Veteran underwent a sleep study. A current diagnosis of obstructive sleep apnea was rendered. The diagnostic impression noted that he was unable to tolerate continuous positive airway pressure (CPAP) therapy. As an alternative, a Provent sleep nasal starter kit was ordered. In March 2017, the Veteran underwent a VA examination. A current diagnosis of obstructive sleep apnea was indicated. During the clinical interview, the Veteran reported use of a Provent nasal kit. However, minimal benefits were reported as the adhesive micro-valves were ill-fitting around the nose. Review of the Veteran's medical history documented a suspicion of obstructive sleep apnea dating back to 2009. A confirmed diagnosis was first rendered following a sleep study in February 2017. No functional impact was indicated. Following the clinical evaluation, the examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran's obstructive sleep apnea is causally related to his service-connected PTSD with depression, NOS. In support of the stated conclusion, the examiner noted a review of research-based medical literature. No "direct and irrefutable" nexus of causation was found between the Veteran's PTSD and the development of obstructive sleep apnea. Obstructive sleep apnea is characterized by recurrent, functional collapse of the velopharyngeal and/or oropharyngeal airway during sleep which resulted in a complete or obstructed airflow. Known risk factors for the development of obstructive sleep apnea include advanced age, gender (more prominent in males), obesity, upper airway abnormalities, congestive heart failure, pregnancy, end-stage renal disease, stroke, and hypothyroidism. As to this Veteran, a history of nasal congestion and smoking were listed as additional risk factors. Considering the above, the Veteran's obstructive sleep apnea was deemed more likely related to his known risk factors to include advanced age, gender, and a lengthy history of excessive smoking. The opinion also indicated that a formal diagnosis was first rendered more than a decade after separation. During a July 2020 Board hearing, the Veteran reported significant trouble initiating and maintaining sleep. He relates the inability to wear the CPAP mask due to symptoms related to his service-connected PTSD. Other symptoms include insomnia, panic attacks, recurrent nightmares, anxiety, and hypervigilance. According to the Veteran, he participated in multiple sleep studies. Minimal benefits were achieved with the alternative treatment, Provent therapy. Thrashing during sleep often causes the mask to dislodge or fall off. At times, the trashing occurs with nightmares and falls out of bed. The Veteran acknowledged use of oral sleep aids, to include Mirtazapine. He sleeps no more than 4-5 hours per night. Daytime fatigue, flashbacks, impaired focus, and concentration were also noted. Other symptoms included mild memory impairment. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. Generally, the Veteran is presumed competent to report on the onset of current symptoms, their impact on daily living and employment, and such reporting is deemed credible. However, as to the etiology of a particular claimed disability, the issue of causation of a medical condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In the instant case, there is no evidence that Veteran possesses the required training to diagnose obstructive sleep apnea or opine as to its etiology, to include on a secondary basis. To the extent his statements may be competent, the Board ultimately assigns greater probative weight to the medical evidence of record, to include opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. While the Board recognizes the Veteran's competence to report on his current symptoms and their onset, the evidence of the record does not support his contention. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). In this case, service treatment records were largely silent for complaints of sleep trouble or a current diagnosis of obstructive sleep apnea. Post-service treatment records confirm a current diagnosis of obstructive sleep apnea on or about 2017. A possible diagnosis was noted several years earlier, in January 2011. Even if the Board were to assume an initial diagnosis was rendered on or about 2011, the Veteran's separation from active service preceded that diagnosis by more than a decade. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for obstructive sleep apnea must be denied. 3. Entitlement to an evaluation in excess of 70 percent disabling for service-connected posttraumatic stress disorder and depression, Not Otherwise Specified (NOS) (to include claimed insomnia) The Veteran contends that the current severity of his service-connected PTSD and depression, NOS is worse than currently evaluated. Review of the record indicates that the Veteran's service-connected psychiatric condition is currently evaluated as 70 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2020). The General Rating Formula for Mental Disorders, including Diagnostic Code 9411, provide the following ratings for psychiatric disabilities: A 70 percent rating contemplates 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); inability to establish and maintain effective relationships. Id. A 100 percent rating contemplates 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. Id. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms listed after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). VA is not required to find the presence of all, most, or even some of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating and permits consideration of other symptoms particular to each veteran and disorder and the effect of those symptoms on the Veteran's social and work situation. Id. Indeed, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Review of the record indicates that the Veteran has received ongoing treatment for his psychiatric symptoms. On examination in September 2011, the Veteran's PTSD symptoms were associated with occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. The examiner identified current symptoms including a depressed mood, anxiety, suspiciousness, near-continuous panic, or depression affecting his ability to function independently, appropriately, and effectively, and chronic sleep impairment. According to the Veteran, he discontinued full-time work as a truck driver due to leg problems and his service-connected PTSD. A preference for work as a truck was noted due to limited contact with the public and minimal direct supervision. The Veteran acknowledged episodes of road rage however, he denied placing others at risk while driving. No specific problems with inappropriate behaviors within the occupational setting were reported. On subsequent examination in August 2015, current diagnoses included chronic PTSD and an unspecified depressive disorder. The Veteran's symptoms were associated with occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Following the clinical interview, the examiner identified current symptoms including a depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, and feelings of hopelessness, guilt and worthlessness. The Veteran reported that he lived alone, isolated himself, and experienced difficulty getting along with other people. No close friendships were identified, his relationship with his two sisters and brother was described as distant. His parents are deceased. In June 2017, an additional VA examination was conducted. The Veteran's current diagnoses included PTSD, dysthymia, moderate alcohol use disorder, and moderate cannabis use disorder. Due to his diagnoses, he avoids social situations, suffers from an inability to work with others, has problems with authority figures, relationship problems, and rarely leaves the house (social isolation). The Veteran's PTSD symptoms were associated with occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgement, thinking and mood. His current symptoms were listed as a depressed mood, anxiety, suspiciousness, and near-continuous panic or depression affecting his ability to function independently, appropriately, and effectively, chronic sleep impairment, impaired judgment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, to include in a work-like setting, an inability to establish and maintain effective relationships, suicidal ideations, and impaired impulse control, such as unprovoked irritability and periods of violence. Other symptoms included night terrors, a persistent exaggerated startle response, negative thought processes and emotional state, an inability to experience positive emotions, anger, and aggression toward authority figures. In a suicide prevention case management record, dated August 2017, the Veteran's struggles with suicidal thoughts were listed as dating back to active service. He denied any history of suicidal attempts. During the clinical evaluation, the Veteran endorsed feeling isolated, with minimal social interactions, mood lability with periods of heightened anxiety. He lives alone on a property with acreage and acknowledged an estrangement from family. During a recent in-patient treatment, the Veteran was prescribed oral psychotropic medications. The Veteran endorsed compliance with the prescribed dosage in April 2017. His prior use of alcohol was in early remission. An evaluation for admission to a Residential Rehabilitation Treatment Program was anticipated in September 2017. One month later, a psychiatric progress note, referenced chronic sleep impairment and depressed mood, rated as a 6 or 7 on a 10-point scale. According to the Veteran, he averages 4 hours of sleep per night. He denied feeling well-rested after sleep and acknowledged fluctuations in his appetite. Other symptoms include loss of energy, and impaired concentration. The Veteran acknowledged problems with social isolation, irritability, loss of interest and motivation. Feelings of worthlessness, and fleeting thoughts of suicide were also reported. While use of alcohol remained in remission, the Veteran admitted periodic use of marijuana. In March 2019, the Veteran was hospitalized in a four-week in-patient treatment program. Current diagnoses included PTSD, Depression, and moderate cannabis use disorder. During the program, the Veteran attended group sessions, participated in group discussions, and met all goals and objectives of the program. He denied any current thoughts of self-harm; the Veteran was deemed competent to manage his own care. Three months later, in June 2019, he underwent a mental health consultation for possible admission to a RRTP program. The evaluation notes documented his recent completion of a 36-day treatment program for symptoms related to PTSD. Since discharge, the Veteran had not engaged in an outpatient treatment program. A less intensive therapy modality was recommended due to his ongoing self-isolation and inability to comply with treatment suggestions. On review of the evidence, the Board finds that medical evidence supports a finding that the Veteran's PTSD symptoms result in total occupational and social impairment. In support of the stated conclusion, the Board notes that the medical evidence confirms ongoing struggles with suicidal ideations, panic attacks, hypervigilance, irritability, aggression, chronic sleep disturbance, nightmares, and social isolation. On multiple occasions, to include April 2015, August 2015, June 2016, February 2017, and February 2019, the Veteran was hospitalized for in-patient treatment due to worsening symptomology. Related treatment records note his struggles with nightmares, poor impulse control, impaired focus and concentration, problems with authority, difficulty with interpersonal relationship functioning, a depressed mood, and suicidal thoughts. Therefore, resolving all doubt in the Veteran's favor, the Board finds that the evidence supports the assignment of a 100 percent rating throughout the appeal period. To that extent, the Veteran's claim is granted. 4. Entitlement to a total disability evaluation based upon individual unemployability The Veteran contends that he is unable to work due to his service-connected disabilities, to include PTSD and depression, NOS. Specifically, he contends that his psychiatric condition has impaired his ability to work since 2008. 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 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2020). 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 Hatlestead 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 age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2020). 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). Review of the record indicates that the Veteran has been granted service connection for PTSD and depression, NOS evaluated as 30 percent disabling from June 15, 2011, 50 percent disabling from October 29, 2014, 100 percent from April 28, 2015, 50 percent disabling from July 1, 2015, 100 percent disabling from August 20, 2015, 50 percent disabling from November 1, 2015, 100 percent disabling from June 16, 2016, 50 percent disabling from September 1, 2016, 100 percent disabling from February 8, 2017, 70 percent disabling from May 1, 2017, 100 percent disabling from February, 4, 2019, and 70 percent disabling from April 1, 2019; right knee chondromalacia evaluated as non-compensable from July 30, 1985; left knee chondromalacia evaluated as non-compensable from July 30, 1985, 10 percent disabling from September 22, 2010, and 10 percent disabling from February 16, 2017; forehead scar evaluated as non-compensable from July 30, 1985; right elbow scar evaluated as non-compensable from July 30, 1985; and left knee scars associated with chondromalacia of the left knee status post meniscus removal evaluated as non-compensable from November 3, 2016. Although the schedular requirements for a TDIU were first met as of October 29, 2014, the remaining question for the Board is whether the Veteran has been rendered unemployable due to his service-connected disabilities. On review of the competent medical evidence and lay testimony of record, the Board concludes that the evidence supports a finding that the Veteran is unemployable due to his service-connected PTSD and depression, NOS. In June 2016, VA-Form 8940 Veterans Application for Increased Compensation Based Upon Unemployability was associated with the record. Therein, the Veteran reported that he last worked full-time, in January 2008. His prior work-related endeavors included many years of work as a truck driver for various trucking companies. According the Veteran, he has been unable to work due to his service-connected PTSD and bilateral knee conditions. During a Board hearing in July 2020, the Veteran indicated that he was unable to work since 2008 due in part, to his psychiatric symptoms. Treatment records show multiple in-patient treatment sessions for PTSD and substance abuse. Despite the structure, the Veteran reported little symptom improvement. He also endorsed little interest in personal care, attending to household chores, or grocery shopping. Considering the above referenced, the Board finds that the medical evidence confirms that the Veteran has rendered him incapable of securing or following a substantially gainful occupation. In reaching this finding, the Board has fully considered all medical evidence and the lay assertions of record. It also acknowledges the Veteran's competence to report on observable symptoms and notes that such statements are generally deemed credible. In this case, the Veteran has been receiving ongoing treatment for his psychiatric symptoms. According to numerous providers, the medical evidence includes a documented history of the Veteran's worsening psychiatric symptoms to include a increasing depressed mood, feelings of hopelessness, social avoidance and isolation, impaired interpersonal relationships, difficulty with authority, irritability, a depressed mood, nightmares, chronic sleep disturbance, problems with memory and concentration, and periodic bouts with suicidal ideations. Moreover, in-patient treatment suggests gross impairments in multiple domains of functioning. Under the circumstances, it is unlikely that the Veteran would be able to work with others, perform occupational tasks with strict timelines, adhere to work-related norms, respond appropriately to direct supervision, or manage work-related task requiring contact with the public. Therefore, resolving all doubt in the Veteran's favor, the Board finds that the evidence supports the assigment of a total disability evaluation. Accordingly, the Veteran's claim is granted. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.