Citation Nr: 22016234 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 09-14 112 DATE: March 21, 2022 ORDER Prior to February 28, 2016, entitlement to a disability rating more than 50 percent for posttraumatic stress disorder (PTSD) is denied. From February 28, 2016, entitlement to a disability rating more than 70 percent for PTSD is denied. Prior to January 7, 2011, entitlement to a total disability rating based on individual unemployability (TDIU) is granted. Entitlement to TDIU from January 7, 2011 is denied. FINDINGS OF FACT 1. For the rating period prior to February 28, 2016, the Veteran's PTSD more nearly approximated occupational and social impairment with reduced reliability and productivity. 2. For the rating period from February 28, 2016, the Veteran's PTSD is manifested by at most occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. 3. Prior to January 7, 2011, the Veteran's service-connected disabilities in the aggregate precluded her from securing and following a substantially gainful occupation. 4. The RO has assigned a 100 percent combined schedular rating from January 7, 2011. CONCLUSIONS OF LAW 1. Prior to February 28, 2016, the criteria for a rating in excess of 50 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. From February 28, 2016, the criteria for a rating in excess of 70 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 3. Prior to January 7, 2011, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 4. From January 7, 2011, the claim for TDIU is rendered moot by the assignment of a 100 percent combined schedular rating. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1982 to January 1994. She also had additional service with the Army National Guard. The Veteran has referred to herself using female pronouns during this appeal and specifically expressed this preference during VA outpatient treatment and the September 2016 Board hearing. The Board will respect this preference. In July 2010 and September 2014 hearings, the Veteran presented testimony before Veterans Law Judges who are no longer employed by the Board. She also presented testimony before the undersigned Veterans Law Judge at a hearing in September 2016. Transcripts of all hearings have been associated with the claims folder. In a June 2018 decision, the Board in pertinent part denied an initial rating greater than 50 percent for PTSD, but granted an increase to 70 percent for PTSD effective February 28, 2016, and declined to adjudicate the claim of entitlement to a TDIU. The Veteran appealed each of those aspects of the Board decision to the United States Court of Appeals for Veterans Claims (Court). The Court issued an order granting the parties' October 2019 Joint Motion for Partial Remand (JMPR) to vacate the June 2018 Board Decision and Remand with respect to the PTSD and TDIU claims and remanded the case back to the Board for compliance with the JMPR. With regard to the claim of entitlement to an increased rating for PTSD, the parties agreed that the Board overlooked favorable evidence or otherwise did not provide an adequate statement of reasons or bases with regard to the Veteran's symptoms of suicidal ideation, hygiene issues, auditory hallucinations, and frequent job changes due to angry outbursts and other impaired impulse control. With respect to the issue of entitlement to TDIU, the parties agreed that the Board erred in not adjudicating the TDIU issue as part and parcel of the increased rating claim for PTSD. The Board most recently remanded the Veteran's claims in May 2021. The Veteran's claims folder has returned to the Board for further appellate consideration. Higher evaluation for PTSD Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § § 4.21 (2020). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § § 4.3 (2020). The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § § 4.1. Where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). When a disability has undergone varying and distinct levels of severity during the appeal, it is appropriate to apply staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is rated as 50 percent disabling prior to February 28, 2016, and 70 percent thereafter under 38 C.F.R. § § 4.130, Diagnostic Code 9411. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § § 4.130, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, a 100 percent rating requires 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. A 70 percent rating requires 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); or inability to establish and maintain effective relationships. A 50 percent rating requires 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; or difficulty in establishing effective work and social relationships. A 30 percent rating requires 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 conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 10 percent rating requires occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A Global Assessment of Functioning (GAF) score is a quantifiable assessment of overall functioning used by mental health clinicians that reflects an individual's "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (both citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), p. 32 (1994)). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). The RO certified the Veteran's appeal to the Board in May 2010; therefore, the claim is governed by DSM-IV. The Board notes that the use of GAF scores has been abandoned in the DSM-5 because of, among other reasons, "its conceptual lack of clarity" and "questionable psychometrics in routine practice." See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). In this case, as the Veteran's case is governed by the DSM-IV, the Board finds that the assigned GAF scores remain relevant for consideration in this appeal, as they were valid under DSM-IV when they were assigned. A GAF score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A GAF score ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideations, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 61 to 70 is defined as some mild symptoms OR some difficulty in social, occupational, or school functioning. A GAF of 71 to 80 is defined as, if symptoms are present, they are transient and expectable reactions to psychosocial stressors. A GAF of 81 to 90 would indicate absent or minimal symptoms and a GAF of 91 to 100 would indicate superior functioning in a wide range of activities; no symptoms. When evaluating mental health disorders, the factors listed in the Rating Schedule are simply 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, 442-43 (2002). The Veteran was provided a VA examination in September 2008. She reported nightmares about her combat in Southwest Asia as well as hypervigilance. She did not report having close friends, although she enjoyed being around her wife. She also reported irritability and had numerous altercations with coworkers and bosses in her employment which resulted in her quitting those jobs. She denied depression, suicidal ideation (but had it in the past), and homicidal ideation. She enjoyed riding her motorcycle, going to the movies, paintballing, and spending time with her wife. She had three children with her first wife and had two stepchildren with her second wife. Upon examination, the VA examiner noted irritability, visual hallucinations, and paranoia. Examination was otherwise normal. The examiner diagnosed her with chronic PTSD as manifest by witnessing combat, nightmares, intrusive thoughts, hypervigilance, anhedonia, social detachment and isolation, avoidance, and irritability. The examiner assigned a GAF score of 60. The Veteran was afforded another VA examination in March 2010. She reported irritability at her places of employment and that she had been employed at four different places since September 2008. She reported a "good" relationship with her wife, although she had almost divorced her in 2009 because of a misunderstanding. She reported some contact with her children from her first marriage, although she had a good relationship with her stepchildren. Although she had no close friends, she was involved in a motorcycle club and a Marine Corps League. She had verbal confrontations on a regular basis and had occasional thoughts of suicide but thought it was a "coward's way out." She denied any current intent to harm herself or others. Upon examination, the VA examiner noted the Veteran was tense and irritable. Her speech was loud at times, and she had an angry and depressed mood. She also had hypervigilance, hyperarousal, and auditory/visual hallucinations. She indicated some memory loss and sleep impairment. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 54. The examiner further noted PTSD symptoms of impairment of short term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. On VA examination in May 2014, the Veteran continued to report a good relationship with her wife generally as well as her children. She also noted a good relationship with her parents and although she struggled to have a good relationship with her in-laws, she remained cordial. She enjoyed riding motorcycles, being in her motorcycle club, and watching movies. She avoided large gatherings due to her irritability and social anxiety. She was unemployed and had been on short-term disability. She worked as a field service technician for a forklift service company. However, in the past six years, she had worked for five different companies and left these jobs due to irritability with coworkers. She noted that in 2013 while in the Virgin Islands, she felt like "swimming home" and swam out to sea. She also periodically considered shooting herself with a handgun. She denied current suicidal ideation, plans, or intent. The examiner documented PTSD symptoms of anxiety and flat affect but noted the Veteran was appropriately dressed and had appropriate thought and speech and denied hallucinations. The examiner opined that the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity. On VA examination in July 2021, the Veteran continued to report a good relationship with her wife and also had a good relationship with some of her children and siblings but had strained relationships with others. She had a limited connection with her peers and community due to her social withdrawal. She had been employed at six different jobs since 2014. She reported that the jobs ended because she was laid off, mutual consent separation, or she quit due to feeling overwhelmed. She had been hospitalized for five days in 2016 at an inpatient facility due to suicidal ideation. The examiner documented PTSD symptoms of anxiety, suspiciousness, panic attacks, chronic sleep impairment, disturbances of motivation and mood, and suicidal ideation. The Veteran has received VA mental health treatment throughout the period on appeal to include participation in group therapy. These records generally show that she managed mild to moderate PTSD symptoms and evidenced symptoms such as depressed mood, anxiety, irritability, and difficulty adapting to stressful situations. Notably, a June 2014 record documented the Veteran's report that her support system primarily included spouse, brother, and a motorcycle club friend. She also reported that she attended a bowling league which had helped reduce social isolation. The Board also notes she had a brief inpatient hospitalization beginning on February 28, 2016. See March 2016 private psychiatric facility discharge summary (describing condition at discharge as "good" and noting no psychoses); see also March 2016 VA outpatient mental health post-hospitalization follow-up notes (observing Veteran not psychotic). VA temporarily flagged her as a high suicide risk. See, e.g., March 2016, April 2016 VA mental health notes. However, this symptom stabilized and improved following her brief inpatient hospitalization beginning in February 2016 and through her post-discharge, ongoing VA outpatient mental health treatment. See March 2016 private psychiatric facility discharge summary (describing Veteran's condition at discharge as "good" and noting no suicidal ideation); see also March 2016 VA outpatient mental health notes (noting passive suicidal ideation with no intent; she stated she would not do anything to harm herself; she affirmed belief that suicide "would make things worse"; reported she had enjoyable weekend with a friend and felt "more optimistic about life"; also reported she was feeling "much better" since hospitalization and was back at work). Moreover, she was found appropriate for discharge and VA outpatient treatment after a relatively brief inpatient stay of less than three days. In addition, despite her temporary placement on a VA high suicide risk list around the time of and soon after her hospitalization, her symptoms stabilized and she no longer met the criteria for placement on this list by summer 2016. See June 2016 VA outpatient mental health note (noting Veteran could be removed from high-risk suicide list and that she denied suicidal ideation); see also July 2016 VA outpatient mental health note. The Veteran also reported symptoms associated with her PTSD at the July 2010, September 2014, and September 2016 Board hearings. In particular, the Veteran testified as to her desire to hurt herself or others, difficulty being around others in an employment setting, inappropriate hygiene, panic attacks, sleep impairment, impaired impulse control, inappropriate behavior, and auditory hallucinations. The Board also notes statements from the Veteran's wife and B.M. who noted the Veteran's irritability and depression. Based on the foregoing, the Board finds that prior to February 28, 2016, the overall severity, frequency, and duration of the mental health symptoms reflect that the Veteran is not entitled to a higher 70 percent disability rating for the service connected PTSD. In this regard, the Board notes that the Federal Circuit held in Vazquez Claudio that "in the context of a 70 percent rating, § 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, 713 F.3d at 116. In this regard, the Board finds that the evidence indicates that the Veteran's PTSD, when considering severity, frequency, and duration of symptoms, is most closely approximated by occupational and social impairment with reduced reliability and productivity. The Board acknowledges that during the period under consideration, the competent and probative medical and lay evidence documents the Veteran's difficulty adapting to stressful circumstances, panic attacks, impaired impulse control, and neglect of personal hygiene. These are criteria found in the 70 percent rating category; however, they cannot be viewed in isolation of the other evidence of the Veteran's overall functioning. When considering the record as a whole, the Board does not find these symptoms to be of such severity, frequency, and/or duration to reach the level of occupational and social impairment considered by a 70 percent (or higher) disability rating. Additionally, while the Board acknowledges the Veteran's social impairment, the evidence does not indicate an inability to establish and maintain effective relationships. Although the Board notes the Veteran's report of social isolation, as well as her report that she does not communicate with some family members, the Veteran has reported a good relationship with her wife and other family members. She has also participated in a motorcycle club as well as group therapy. In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that "the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas" correlating with a 70 percent evaluation under the rating criteria. Id. at 20 (emphasis added). The key word in the quote above, taken verbatim from the Bankhead decision, is "may" which is merely suggestive. Thus, the Court declined to hold that the presence of suicidal ideations automatically entitles a veteran to a 70 percent evaluation under the rating criteria in every situation. Rather, "VA must engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment." Bankhead, 29 Vet. App. at 22 (internal citations omitted). Here, viewing the evidence as a whole, the record does not show that prior to February 28, 2016, the Veteran experienced suicidal ideation that affected her social and occupational functioning to the extent required for a higher rating. The Board acknowledges the Veteran's report of suicidal ideation at the March 2010 VA examination, July 2010 Board hearing, September 2014 Board hearing, May 2014 VA examination, and in VA treatment records. However, the Veteran also repeatedly denied suicidal ideation or intent throughout her VA examinations and VA treatment records during the period under consideration. Indeed, she generally managed this symptom effectively with regular VA outpatient treatment and psychotropic medications. Therefore, the Board finds that the record as a whole, including the Veteran's suicidal ideation, does not reflect symptomatology or deficiencies in most areas, particularly, work, judgment, thinking or mood such that a higher 70 percent rating is warranted prior to February 28, 2016. In light of the foregoing, the Board concludes that, while the Veteran demonstrates some of the criteria commonly associated with a 70 percent disability rating, the evidence of record does not show that her overall disability picture, when considering the severity, frequency, and duration of the mental health symptoms, more closely approximates the criteria for a 70 percent (or higher) disability rating under 38 C.F.R. § 4.130 prior to February 28, 2016. Moreover, there are no other factors which would lead the Board to conclude that a 70 percent (or higher) disability rating is warranted. See Mauerhan, supra [the specified factors for each incremental rating are examples rather than requirements for a particular rating; analysis should not be limited solely to whether the claimant exhibited the symptoms listed in the rating scheme]. Rather, the level of functioning is greater than that contemplated by the 70 percent rating category. The Board finds that the evidence as whole indicates that the Veteran's PTSD traits also include hyperarousal, intrusive thoughts, feelings of isolation, and hypervigilance. In consideration of these symptoms with the Veteran's other PTSD symptoms, the Board finds that these criteria do not approximate a 70 percent disability rating or higher as they are not of such a severity or frequency to result in occupational and social impairment with deficiencies in most areas. The Board further finds that from February 28, 2016, a 100 percent disability rating is not warranted for the Veteran's PTSD. While the Board accepts that the Veteran's PTSD symptoms significantly affect her functioning, the lay and medical evidence of record does not demonstrate both total occupational and social impairment. The Board acknowledges the evidence that indicates the Veteran has difficulty maintaining personal hygiene and she has had hallucinations. The Board also notes the Veteran's hospitalization in 2016 for suicidal intent. However, the evidence does not demonstrate symptoms such as gross impairment in thought process or communication, grossly inappropriate behavior, persistent danger of hurting others, disorientation to time or place, or memory loss for names of close relatives or own name, or other symptoms on a par with the level of severity exemplified in these manifestations. On the contrary, the Veteran has overall been found to have appropriate thought process and communication and has been oriented to time and place. The Board also reiterates the July 2021 VA examiner's assessment of the Veteran's PTSD as occupational and social impairment with reduced reliability and productivity and that the Veteran was a low acute risk of suicide. As such, the Board finds that the record as a whole does not support the existence of symptoms such that there is total occupational and social impairment from February 28, 2016. The Board further notes that as indicated above, the evidence of record reflects that the Veteran has symptomatology including sleep impairment, hyperarousal, intrusive thoughts, feelings of isolation, and hypervigilance. These symptoms are fully contemplated in the assigned 70 percent evaluation. However, the Board finds that such symptoms do not more nearly approximate a 100 percent rating as they are not of such a severity or frequency to result in total occupational and social impairment. The Board further finds the VA examination findings in particular to be of great probative value in that the examiner did not indicate that the Veteran's psychiatric disorder was manifested by total occupational and social impairment. Based on all of the above, the Board finds that a disability rating more than 70 percent is not warranted from February 28, 2016. The Board also observes that the Veteran has been assigned GAF scores between 44 and 65, which is indicative of serious to moderate impairment. However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue. The GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Given the actual psychiatric symptoms shown in this case, the Board finds that level of overall psychiatric impairment is shown to be consistent with the current assigned ratings. In summary, the Board finds that a disability rating more than 50 percent prior to February 28, 2016, and a rating more than 70 percent thereafter is not warranted. TDIU Total disability ratings for compensation based on individual unemployability 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. §§ 3.340, 3.341, 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities. 38 C.F.R. § 4.16(b). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Prior to January 7, 2011 Prior to January 7, 2011, the Veteran's service connected disabilities were the following: PTSD, rated as 50 percent disabling; migraine headaches, rated 30 percent disabling; bilateral plantar fasciitis, bilateral acquired pes cavus (claw foot), and osteoarthritis at the bilateral first metacarpophalangeal and interphalangeal joints, rated 30 percent disabling; left knee degenerative arthritis, rated 10 percent disabling; right knee degenerative arthritis, rated 10 percent disabling; irritable bowel syndrome, rated 10 percent disabling; osteoarthritis and strain of the left hip, rated 10 percent disabling; lumbosacral strain, rated 10 percent disabling; tinnitus, rated 10 percent disabling; and rhinitis, rated 10 percent disabling. Her combined rated was 90 percent. She therefore satisfies the schedular requirement for consideration of TDIU. The Veteran contends that her service-connected PTSD as well as her service-connected orthopedic disabilities preclude her from substantial gainful employment. See, e.g., TDIU claim received by VA dated August 2013. The record reveals that the Veteran worked during the period under consideration as a field service technician/mechanic. Id. Based on review of the evidence of record, the Board finds that the Veteran was precluded from substantial gainful employment prior to January 7, 2011. Specifically, although the Veteran has reported employment only at Arnold Machinery during the period under consideration on her August 2013 and March 2014 TDIU claims, she also reported during a March 2010 VA mental health examination as well as during the July 2010 Board hearing that she worked at numerous companies during this period. Pertinently, the Veteran's reason for her working at many different companies during the period under consideration was due to her inability to function in stressful situations and her irritability, in particular towards coworkers and supervisors. Thus, while the record indicates the Veteran was able to obtain gainful employment, she was not able to maintain such. Notably, an October 2014 Vocational Counseling Record reveals the Veteran had a Serious Employment Handicap (S.E.H.) and further documented the Veteran has psychological issues of depression and anxiety and physical disability of the knees where she was not able to sit, stand, walk or lift for prolonged periods. She also lacked the education to obtain suitable employment. The Board also notes the March 2010 VA mental health examiner's report of the Veteran's "angry, anxious and depressed overall mood" and impairment of functioning in the area of employment. The examiner also noted the Veteran's inability to fit in with colleagues at work and conflict with supervisors and customers. The Board adds that with consideration of the Veteran's service-connected orthopedic disabilities and headaches, while the Veteran reported during a December 2009 VA examination that she was able to do her usual work, she was slower than others in doing so due to the impact of these disabilities. In light of the foregoing, the Board finds that the Veteran's mental limitations from her service-connected PTSD in combination with her service-connected orthopedic disabilities and migraine headaches rendered her unable to obtain and retain substantial and gainful employment prior to January 7, 2011. Accordingly, the Board concludes that entitlement to a TDIU is warranted prior to January 7, 2011, and the Veteran's claim is therefore granted. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. The effective date is controlled by the date of the Veteran's claim for PTSD which is April 24, 2008. From January 7, 2011 From January 7, 2011, the Veteran is in receipt of a 100 percent combined rating for her service-connected disabilities. Thus, the Board finds that the issue of TDIU from January 7, 2011, is moot as the Veteran has a 100 percent combined rating from this date. The Board is cognizant of the decision in Bradley v. Peake, 22 Vet. App. 280 (2008); however, the facts in this case are distinguishable from Bradley, which involved the assignment of a TDIU (total rating) based on a single "less than total" (70 percent) disability rating with subsequently claimed additional orthopedic disabilities that combined to 60 percent. The instant case, however, is distinguishable from Bradley in that here, the Veteran is now in receipt of a 100 percent combined schedular rating for multiple disabilities effective from January 7, 2011. Any TDIU granted would necessarily be based on all the service-connected disabilities. See 38 C.F.R. § 4.16. If the Veteran were to be awarded a TDIU based on all the service-connected disabilities, which are already rated at a combined disability rating of 100 percent, it would impermissibly result in the same disabilities being "counted twice" in the assignment of a total rating. See generally 38 C.F.R. § 4.14 (2020). For these reasons, the Board finds that the TDIU claim is rendered moot from January 7, 2011. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Arif Syed, 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.