Citation Nr: 22017351 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 15-22 933A DATE: March 24, 2022 ORDER Entitlement to an initial rating of 70 percent for post-traumatic stress disorder (PTSD), but no higher, is granted. Entitlement to a rating of total disability based on individual unemployability (TDIU) is granted as of April 3, 2013. REMANDED Entitlement to service connection for a left elbow disability is remanded. FINDINGS OF FACT 1. Symptoms of an acquired psychiatric disorder most closely approximate occupational and social impairment with deficiencies in most areas throughout the period on appeal. 2. Throughout the period on appeal, the Veteran's service-connected disabilities have rendered her unable to secure or maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to a rating of total disability based on individual unemployability (TDIU) have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1992 to May 1992, from February 2003 to November 2003, from September 2004 to May 2005, from October 2005 to December 2007, from June 2008 to September 2008, from March 2009 to June 2009, from July 2009 to February 2010, from April 2010 to July 2010, and from August 2010 to June 2011. This case comes on appeal of a March 2014 rating decision. In August 2019, the Veteran testified before the Board at a videoconference hearing. In August 2020, the Board issued a decision in which it, in pertinent part, remanded the issues of entitlement to service connection for a left elbow disability and entitlement to an increased initial rating for PTSD for further development. Notably, the Veterans Law Judge who conducted that hearing and issued that decision is no longer with the Board. In August 2021, VA notified the Veteran of this fact and offered the Veteran the opportunity to testify at a new Board hearing. The Veteran was informed that if she did not respond within 30 days, the Board would assume that the Veteran did not wish to have another hearing. Indeed, the Veteran did not respond. Moreover, the Veteran's representative submitted an appellate brief in January 2022, stating that the appeal was considered sufficient to proceed for review. Therefore, the Board considers the Veteran's desire for a hearing to be satisfied. The Board also notes that, following the agency of original jurisdiction's (AOJ) issuance of a supplemental statement of the case (SSOC) on these matters in June 2021, the Veteran underwent a new VA PTSD examination in October 2021. Since this examination took place and was uploaded to the Veteran's file after the most recent SSOC, the AOJ did not have the opportunity to review this evidence in the first instance. However, in February 2022, the Veteran, through her representative, submitted a waiver of AOJ review in the first instance of all evidence received after the June 2021 SSOC. Accordingly, the Board proceeds in its review of the claim without the need to remand for AOJ review. 1. Entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD) prior to November 30, 2020, and in excess of 70 percent thereafter Disability evaluations are determined by the application of the facts presented to the 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. § 4.1. 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. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. (1999); Hart v. Mansfield, 21 Vet. App. (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. The Veteran filed a claim of entitlement to service connection for PTSD in April 2013. In the March 2014 rating decision on appeal, the AOJ granted in entitlement to service connection for PTSD at a rating of 50 percent. The Veteran submitted a notice of disagreement with the rating of the disability and ultimately appealed to the Board. As was discussed above, in August 2020, the Board remanded the issue for further development, to include affording the Veteran a new examination. Following the Board's remand, in June 2021, the AOJ issued a rating decision granting entitlement to a rating of 70 percent for PTSD, effective the date of the Veteran's November 30, 2020, VA examination. However, the Veteran is presumed to seek the maximum benefit available under the law. AB v. Brown, 6 Vet. App. 35, 38 (1993). As the June 2021 decision represented only a partial grant of benefits, the issue remains on appeal. Therefore, the Board reviews whether the Veteran is entitled to an initial rating in excess of 50 percent prior to November 30, 2020, and in excess of 70 percent thereafter. The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. For rating purposes, Diagnostic Code 9411 is included among the General Rating Formula for Mental Disorders ("Rating Formula") of 38 C.F.R. § 4.130. To be assigned a rating of 50 percent, the Veteran must demonstrate occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly-learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. To be assigned a rating of 70 percent, the Veteran must demonstrate 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 that is 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. To be assigned a rating of 100 percent, the Veteran must demonstrate total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). In Vasquez-Claudio v. Shinseki, F.3d 112, 117 (Fed. Cir. 2013), the Court also held that a Veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Indeed, considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Post-service treatment records show that the Veteran underwent an outpatient psychiatric consult with VA in December 2013. There the Veteran presented with complaints of depressed mood, in part due to the loss of a child via miscarriage, as well as a lack of future plans for herself. She related feeling alone and fearful due to having few relatives left in her life. She reported frequent crying, despite being embarrassed by this behavior, as well as other depressive symptoms. In January 2014, the Veteran underwent a VA PTSD examination. There, the examiner reported diagnoses of PTSD and depressive disorder. The examiner reported that PTSD was related to military traumas, but that depressive disorder was related to the loss of child combined with the stresses of a job loss and marital conflicts. According to the examiner, it was possible to differentiate between the symptoms of PTSD and depression. The examiner noted symptoms of PTSD, to include: persistent, distressing recollections of trauma; persistent symptoms of avoidance and emotional numbing; and persistent symptoms of increased arousal, such as irritability, hypervigilance, and exaggerated startle response. Symptoms of depressive disorder included: depressed mood; difficulty motivating self; episodic feelings of hopelessness; relationship problems; and unemployment. The Veteran stated that she lived with her husband and two pet dogs. She reported having some friends and acquaintances. At that time, she had been unemployed for approximately 18 months, after losing her job as an intelligence analyst for the Department of Homeland Security. The examiner observed that the Veteran was dressed and groomed appropriately, and was alert and oriented to all spheres. She exhibited a subdued mood and affect and demonstrated episodic tearfulness when discussing trauma exposure. In a VA pharmacy note just a few days after the VA examination, the treating provider reported that the Veteran was experiencing some depression and crying episodes. She noted getting emotional and needing to avoid the news. She described having more good days than bad, but also admitted that she did not feel happy. Although the Veteran denied panic attacks at that time, she stated that she had difficulty being in crowds and acknowledged a constant feeling of being overwhelmed. She had low energy and poor motivation, and described having to force herself to do basic things. Her concentration was fair, but she reported that her memory was not as good as it once was, and that she found herself forgetting small things regularly. She denied suicidal or homicidal ideation at that time, but endorsed exaggerated startle response and hypervigilance. In a March 2014 VA therapy session, the Veteran stated that she did not feel she was ready to go back to work, after losing her job in 2012. She reported feeling overwhelmed and not even knowing how she would start the process of a new job. The Veteran continued in group therapy during 2014, with a goal of taking action steps to get out of depression. Her therapist noted that this was a very important goal. In a November 2014 VA pharmacy note, the Veteran reported feeling like her life had no purpose. She described her mood as feeling like she was treading water and that she was experiencing crying episodes. She denied panic attacks at that time, although admitted that she had nearly had one the day of her recent wedding ceremony. She continued to report feeling overwhelmed by basic functions. Energy and motivation remained poor. The Veteran reported having a few friends, but would make excuses not to go out with them. She continued to deny suicidal or homicidal ideations at that time, but again endorsed exaggerated startle response and hypervigilance. In December 2015 treatment, the Veteran acknowledged isolating at times. She reported that she sometimes would not leave the house for days at a time. She continued not to feel comfortable in crowds and admitted to feeling overwhelmed by things she felt should not overwhelm her. The Veteran denied panic attacks at that time, but acknowledged experiencing weekly nightmares related to deployment and other experiences that were out of her control. Her motivation continued to be poor and she continued to struggle with forcing herself to perform basic tasks. On mental status examination, the Veteran was noted to have a dysthymic mood with congruent, but brighter affect. Her speech was within normal limits, her thought process was logical, and she denied suicidal or homicidal ideations. In a March 2016 VA treatment session, the provider's diagnostic assessment was PTSD and major depressive disorder, as well as panic disorder with agoraphobia. The Veteran reported that she had been nannying a friend's 13-month-old baby two times a week, but that this had been overwhelming due to her anxiety. She reported experiencing some crying spells along with some anger and irritability. Her sleep had been broken lately, despite medication, and she continued to experience nightmares once or twice per week. She continued to endorse an exaggerated startle response and hypervigilance, but denied suicidal or homicidal ideation at that time. At that time, the Veteran reported working part-time in photography and trying to get her own business, but not being successful in doing so. She also had a horse and would sometimes take people out for guided tours. She exhibited resentment and anxiety toward a male colleague in her last full-time job whom she felt had harassed her and gotten her fired. The Veteran noted that her husband was gone during the week due to his job and that her interest level in doing things was not good. She reported that she was staying at home more and not meeting friends. She stated that she had been very active prior to her active duty deployment, but she had not been the same since returning from Iraq in 2008. She acknowledged having intermittent suicidal ideations over the prior three years, but no plan. Rather, she just felt at times that there was no reason for her to be alive. The provider noted no abnormal speech or movements and no slowing. The Veteran's mood was anxious and dysphoric with a mildly restricted affect. Her thought process was linear and she had no hallucinations, illusions, or delusions. Her insight and judgment were good and she was alert and oriented to all spheres. The Veteran then begin additional group counseling with VA. In a January 2017 note, the Veteran reported that she had felt that prior cognitive behavioral therapy for depression had been helpful. She stated that depression at that time was around losing her identity that she had due to service, followed by the loss of her job and her miscarriage. She expressed the need to control her panic attacks and anxiety, having experienced two panic attacks recently. She reported that she got overwhelmed easily and that she always felt anxious. The Veteran reported that she was hoping to attend a cognitive behavioral therapy group for anxiety when it opened, and another therapy group until that time. The provider noted that facilitators may want to consider allowing the Veteran to be in both groups at one time as it appeared she needed "a lot of support." The Veteran then submitted a May 2017 PTSD disability benefits questionnaire (DBQ) completed by D.M., a licensed therapist. D.M. reported diagnoses of PTSD, depressive disorder, and anxiety disorder, and opined that it was not possible to differentiate the symptoms from one another. D.M. reported symptoms to include: depressed mood; anxiety; suspiciousness; panic attacks at least weekly; chronic sleep impairment; mild memory loss; impairment of short and long term memory; flattened affect; speech intermittently illogical, obscure, or irrelevant; difficulty in understanding complex commands; impaired judgment; disturbances of motivation and mood; difficulty adapting to stressful circumstances; inability to establish and maintain effective relationships; suicidal ideation; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. D.M. opined that the Veteran's symptoms resulted in occupational and social impairment in most areas. Specifically, D.M. noted that the Veteran had experienced difficulty in finding and keeping a job due to increasing PTSD symptoms of insomnia, panic attacks, high anxiety, irritability, hypervigilance, social isolation, rumination thoughts, suicidal thoughts, difficulty concentrating, and memory issues. The Veteran then underwent a new VA examination in February 2018. There, the examiner diagnosed PTSD and unspecified depressive disorder. The examiner once again opined that it was not possible to differentiate between the two diagnoses due to symptom overlap. The Veteran described symptoms of social anxiety and panic attacks, including chest tightness and the feeling of being unable to get air in, as well as helplessness and sweating. She reported fearing panic attacks. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty adapting to stressful circumstances including work or a work-like setting. The Veteran endorsed suicidal ideation, but had no intent or plan. The examiner reported that the Veteran was well groomed and was alert and oriented to all spheres, with no evidence of psychomotor disturbance. Her mood and affect were depressed, and she answered questions at times tearfully and slowly. There was no evidence of thought disorder or delusional thinking. Insight was present, and judgment and impulse control appeared adequate. Following the Board's August 2020 decision, the Veteran then underwent a new VA examination in November 2020. There, the examiner diagnosed PTSD and major depressive disorder, opining again that it was not possible to differentiate symptoms due to symptom overlap of comorbid conditions. The Veteran reported to the examiner that she had been unemployed for approximately eight years. In 2012, she was working for the federal government. She was having a lot of anxiety at work and tried to get help, however, she was not getting support and a male coworker was verbally abusive to her. She was going home and having breakdowns on a nightly basis and ultimately got fired before her probationary period was over. The Veteran stated that she had been experiencing more social anxiety and did not go out very much. She reported getting groceries and doing necessary tasks. She had been trying to seek counseling but could not participate in VA counseling since she had moved to Mexico for a cheaper cost of living. The examiner reported symptoms, to include: depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; impairment of short and long term memory; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; neglect of personal appearance and hygiene; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Although the examiner did not check the box to report suicidal ideations as a symptom, the Veteran reported passive suicidal ideation as recently as the prior week. The Veteran also reported that her marital situation had worsened and that she and her husband had been sleeping in separate bedrooms. The Veteran then underwent an additional VA examination in October 2021. There, the diagnosis and assessment remained unchanged. The Veteran reported that she and her husband were sleeping in separate bedrooms and she tended to isolate, even when they were at home together. She reported that she was not keeping in touch with friends, as she felt no one understood her and that she was being judged. She was, however, remaining in touch with her mother and brother. She reported having difficulty driving herself and would become overwhelmed when doing so. The Veteran stated that she had not worked since 2012, except for some rideshare driving in 2016. She described significant difficulty with panic attacks and was overwhelmed when faced with responsibility and task completion. Depression and lack of motivation made daily tasks difficult to manage at times. Her concentration was also impacted, and she noted having difficulty following instructions for things like recipes. The Veteran reported thoughts of suicidal ideations, but denied intention or a plan to harm herself, identifying her husband and brother as protective factors. The examiner reported symptoms, to include: depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss; impairment of short and long term memory; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; suicidal ideation; neglect of personal appearance and hygiene; intermittent inability to perform activities of daily living. On observation, the Veteran was adequately dressed and groomed for the session. She was cooperative and made appropriate eye contact. Her speech and motor activity appeared to be within a normal range and her thought content and thought process appeared normal. She denied hallucinations and was absent of delusions. She also denied homicidal ideations. Additionally, the examiner observed symptoms of low self-worth, changes in appetite, fatigue, and hopelessness. At her April 2019 Board hearing, the Veteran further elaborated on some of her symptoms and experiences. She described every day as a struggle due to depression, panic attacks, and social anxiety. Specifically, she noted that it was very hard for her to keep calm and keep the anxiety under control. She found herself unable to get a job that she could feel comfortable keeping, mainly because she would wake up every day unsure if she could handle the day. The Veteran explained that she avoided having any obligations because the anxiety of worrying whether or not she could do them correctly was so overwhelming that she would essentially shut down. As an example, she noted that a friend who had an independent bartending business had hired her to serve drinks at a wedding. Even the concern over being able to serve people and to mix drinks proved to be an overwhelming level of stress for her. Based on this evidence, the Board finds that an initial rating of 70 percent, but no higher, is warranted throughout the period on appeal. First, the Board notes that, although the January 2014 examiner stated that it was possible to differentiate between symptoms of PTSD and depression, numerous subsequent examiners have opined that such is not the case. Accordingly, the Board considers the full array of the Veteran's mental health symptoms in evaluating this appeal. The Board recognizes that the Veteran's condition has clearly worsened from the date of her initial claim to the present. Indeed, looking solely at the Veteran's VA examinations, the condition appears to be significantly less severe at the time of the claim compared to the October 2021 examination. However, the Board notes that those examinations represent only a snapshot of the Veteran's condition on particular days, and the Board's role in this adjudication is to evaluate the overall level of severity with consideration of frequency and duration of symptoms. Moreover, the ultimate determining factor in assigning a disability rating in this case is not whether specific symptoms meet specific rating criteria, but rather the Veteran's overall social and occupational impairment during the pendency of the claim. In that regard, the Board pays special notice to the Veteran's consistent descriptions of feeling overwhelmed by basic tasks that she has given throughout the period on appeal. The April 2019 Board hearing gave the Veteran the opportunity to expound upon this symptom that was listed without much explanation throughout the Veteran's medical records. In doing so, the Veteran described a situation in which she did not just have negative feelings, but in fact was effectively shutting down due to the anxiety associated with these feelings. Combined with the Veteran's regular crying spells and avoidance of social situations, to include making excuses not to see friends, this indicates significant occupational and social impairment throughout the period on appeal. Indeed, as the Veteran's January 2017 group therapy provider noted, it appeared as though the Veteran needed "a lot of support." Moreover, although she denied active intent or plans for suicide throughout, the Veteran has described regular suicidal ideations over the appeal period. This regular feeling that she would be better off if she were not alive is evidence of a more severe disability from the date of the claim. As was stated above, 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. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Here, although the Veteran's mental health symptoms increased in severity over the pendency of this claim, resolving all reasonable doubt in the Veteran's favor, the Board finds that the symptoms more closely approximate the criteria of a 70 percent rating throughout the entire period on appeal. Therefore, an initial rating of 70 percent is granted. The Board has considered whether the Veteran's symptoms warrant a 100 percent rating at any point during the appeal period and has determined they do not. As was discussed above, to be assigned a rating of 100 percent, the Veteran must demonstrate 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. Here, although the Veteran's symptoms, especially those described in her most recent VA examinations, document significant social impairment, they do not document total social impairment. Indeed, though the Veteran has indicated difficulties in her marriage, she and her husband have remained married throughout the period on appeal. Additionally, the Veteran has maintained a relationship with her mother and brother. She referred to both her husband and brother as protective factors in preventing her from having suicidal intent. Moreover, the Veteran has not demonstrated gross impairment in thought process or communication, delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting herself or others, disorientation to time or place, or memory loss of names of close relatives or her own name. Notably, at the Veteran's most recent VA examination in October 2021, the examiner did report an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. However, the Veteran has always reported to examinations and treatment sessions adequately dressed and groomed and has not demonstrated cause for concern in any of her other medical appointments of record. Although the Veteran has described her concentration issues as affecting her ability to follow recipes, there is no indication that she is unable to complete basic tasks such as feeding herself as a general matter. Accordingly, the evidence persuasively favors a finding that the Veteran's PTSD does not result in total social impairment at any point during the period on appeal. Therefore, the Board finds that the Veteran's PTSD warrants an initial rating of 70 percent, but no higher, throughout the period on appeal. 2. Entitlement to a rating of total disability based on individual unemployability (TDIU) It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16. In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training and previous work experience, but not to his or her age or to any impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. A total disability rating for compensation may be assigned where the schedular rating is less than total when the disabled person is, in the judgment of the rating agency, 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. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. See 38 C.F.R. § 4.16(a). For consideration under these provisions, disabilities resulting from common etiology or a single accident will be evaluated as one disability. Id. Pursuant to 38 C.F.R. § 4.16(b), when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), such case shall be submitted for extraschedular consideration. The ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). As such, the focus of the examiner is not on whether the Veteran is unemployable due to his or her service-connected disabilities, but the functional impairment caused solely by his or her service-connected disabilities. When the issue of entitlement to a TDIU is raised by the Veteran or by the record during the pendency of an increased rating claim, the matter is considered to be part and parcel of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (noting that a TDIU claim is implicit to a claim of increased rating when raised by the record during the pendency of the increased rating claim). Here, the issue of TDIU was raised by the record during the pendency of the Veteran's claim of an increased initial rating for PTSD. Therefore, the Board considers the issue of TDIU to stem from the date of that claim as well. The Board notes that the AOJ issued a July 2021 rating decision in which it denied a TDIU. Nevertheless, as the Veteran's increased rating appeal is currently before the Board, the issue of TDIU remains on appeal as well. The Veteran filed the claim of entitlement to a TDIU on April 3, 2013. As of that date, the Veteran was service connected for: PTSD and depressive disorder, at a rate of 70 percent; bilateral flat foot, with bilateral metatarsalgia, bilateral plantar fasciitis, bilateral degenerative joint disease, and right great toe implant with right hallux rigidus, at a rate of 50 percent; symptomatic premature ventricular contractions, at a rate of 30 percent; restrictive lung disease, at a rate of 10 percent; gastroesophageal reflux disease, at a rate of 10 percent; right lateral epicondylitis, at a rate of 10 percent; scar at the posterior trunk area, at a rate of 0 percent; bilateral tinea pedis and onychomycosis, at a rate of 0 percent; and deep acne cysts, at a rate of 0 percent. The combined rating for these disabilities has been 90 percent since the date of the claim. Therefore, the Veteran has been schedularly eligible for TDIU under 38 C.F.R.§ 4.16(a) during this entire period. As of June 21, 2016, the Veteran was also rated at 0 percent for a right elbow scar, however this does not affect the overall disability rating. However, the Board notes that the Veteran was assigned a temporary 100 percent rating from June 21, 2016 to August 1, 2016, secondary to convalescence for right elbow surgery. At issue, then, is whether the Veteran has been unable to secure or follow a substantially gainful occupation due to service-connected disabilities. The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. The economic component requires a determination as to whether a Veteran's income exceeds the poverty threshold. The noneconomic component requires a determination as to a Veteran's ability to secure and follow such employment. With regard to the latter component, attention should be given to the Veteran's history, education, skill, and training. Consideration should also be given to both the Veteran's physical and mental abilities. From a physical standpoint, possible relevant factors include the Veteran's limitations as to lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as audio and visual limitations. Regarding the Veteran's mental ability, possible relevant factors include limitations as to memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. See Ray v. Wilkie, 31 Vet. App. 58 (2019). In determining whether unemployability exists, consideration should not be given to the Veteran's age or to any impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. From an economic perspective, the Veteran last worked full-time in 2012, prior to filing this claim. The record indicates that the Veteran has also attempted a number of part-time positions with little success. These have included working for a friend as a wedding bartender, working as a self-employed photographer, and working as a rideshare driver. There is no indication that the Veteran was able to sustain such employment. Moreover, especially in the case of the wedding bartender jobs, it appears that this was a protected work environment due to the nature of the Veteran's friendship with the business owner. Resolving all reasonable doubt in the Veteran's favor, the Board does not have reason to believe that the Veteran has engaged in substantially gainful employment since losing her job in 2012. From a non-economic perspective, the Board has described at some length above the Veteran's occupational impairment due to PTSD and depressive disorder. Indeed, the Veteran's psychiatric symptoms caused her to feel severely overwhelmed with basic tasks such that regular work was not possible. She also experienced uncontrolled crying spells, irritability, and occasional suicidal ideations. The Veteran's treating providers noted the Veteran's need for significant support, to include attendance at multiple group therapy programs, which would also not be conducive to maintaining a regular work schedule. Additionally, throughout the period on appeal, the Veteran has experienced significant pain and limitation due to her bilateral foot condition. Thus, even if the Veteran were able to find employment that allowed her to avoid the stress associated with working with or for other people, she would be further limited by the physical manifestations of her foot disability. Based on this, the Board resolves all reasonable doubt in the Veteran's favor to find that the Veteran's service-connected disabilities have rendered her unable to secure or maintain substantially gainful employment since the date of her April 3, 2013, claim. Accordingly, entitlement to a TDIU is warranted from that date. REASONS FOR REMAND Entitlement to service connection for a left elbow disability is remanded. The Board previously remanded this claim to address the Veteran's contention that a left elbow disability was caused or aggravated by her service-connected right elbow disability, to include as due to overuse of the left elbow. The Veteran underwent an examination to address this in June 2021. At that time, the examiner relayed the Veteran's reports that she no longer experienced left elbow issues following her right elbow surgery. However, there is evidence to show that the Veteran did experience left elbow symptoms during the claim period. Therefore, there is evidence of a current disability during the claim period, even if the symptoms of that disability have resolved. Thus, there remains an open medical question as to whether any such disability during the claim period was caused or aggravated by the service-connected right elbow disability. Accordingly, on remand, an additional medical opinion is necessary. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate examiner addressing the Veteran's left elbow disability. The examiner should review the claims file, to include a copy of this Remand, and the opinion should include discussion of the Veteran's documented history and assertions. The examiner should identify all disabilities of the left elbow, to include any functional impairment due to pain, evident at any point since the Veteran filed her claim in April 2013. Then, with respect to such disability, the examiner should render an opinion, as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the disability was caused or aggravated by the Veteran's service-connected right elbow disability. In doing so, the examiner should note that an opinion is necessary as it pertains to any time during the claim period during which the Veteran demonstrated a left elbow disability. Thus, even if the examiner finds that the Veteran's left elbow disability has resolved, an opinion is still necessary as to whether the Veteran's right elbow disability caused or aggravated the left elbow disability, to include as due to overuse of the left elbow. To the extent that the examiner cannot provide such an opinion without physical examination of the Veteran, such examination should be arranged. The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. Complete rationale should include an explanation of the evidence used in support of the conclusion, as well as an explanation as to why such evidence supports the conclusion. 2. Once the above development has been achieved, as well as any other development deemed necessary thereafter, readjudicate the appeal. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Giaquinto, 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.