Citation Nr: 22018116 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 19-24 847 DATE: March 28, 2022 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. Entitlement to an initial rating in excess of 50 percent for PTSD is denied. Effective November 1, 2021, entitlement to a finding of total disability based on individual unemployability due to service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. Currently diagnosed obstructive sleep apnea is caused or aggravated by the Veteran's service-connected PTSD. 2. Throughout the period on appeal, the Veteran's PTSD was manifested by symptoms which most closely approximate occupational and social impairment with reduced reliability and productivity. 3. Since November 1, 2017, the Veteran's service-connected disabilities precluded gainful employment consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected PTSD, have been met. 38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. Throughout the period on appeal, the criteria for an initial evaluation rating in excess 50 percent have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.21, 4.130, Diagnostic Code 9411. 3. Effective November 1, 2017, the criteria for entitlement to TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from October 1989 to November 2003. He was then a member of the Army National Guard, with periods of active-duty service from July 2005 to December 2006 and from August 2012 to October 2013. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision of the agency of original jurisdiction (AOJ) of the United States Department of Veterans Affairs (VA). The February 2015 rating decision denied entitlement to service connection for obstructive sleep apnea and granted entitlement to service connection for PTSD with an assigned rating of 50 percent effective October 19, 2013. The Veteran testified at a September 2021 videoconference hearing held before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. The Veteran's request to hold the record open for 60 days for the submission of additional evidence was granted, and subsequently additional evidence was timely submitted. The Veteran testified that he was medically retired from his job in October 2017 and that his service-connected conditions unduly interfered with his ability to follow substantially gainful employment. A claim for a finding of total disability based on individual unemployability is therefore inferred as part of the claims for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his representative has advanced any procedural arguments in relation to VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Although the record indicates there may be some outstanding medical records, they do not appear pertinent to the Veteran's PTSD claim. Sleep Apnea Service connection is awarded for disability that is the result of a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F. 3d 1163 (Fed. Cir. 2004). 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. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability that are subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Service treatment records (STRs) do not indicate a diagnosis of sleep apnea while the Veteran was in a period of active duty. They do show that a line of duty determination was sought for OSA as a National Guard member. This was initially endorsed by his local command in February 2015, with the finding that the Veteran had difficulty sleeping due to service-connected PTSD, and took sleep medication. He was subsequently diagnosed with sleep apnea "due to [mental health] concerns." The state Adjutant General approved this in November 2015, citing a January 2015 statement from the Veteran's doctor that weight was not the cause of the Veteran's sleep apnea, and reasoning no cause other than the mental disorder was present. However, the Federal National Guard Bureau, the overall command, rejected these lower findings and found OSA was not incurred in the line of duty. They cited the lack of actual substantial evidence supporting a positive determination (required by regulation), and contrary evidence showing an increase in body mass index (BMI) and counseling by medical professionals to lose weight. The Veteran receives private medical treatment and medical treatment through the VA. The Veteran's medical records indicate that since being diagnosed with sleep apnea he continues to be treated for it with a breathing machine and medication. In his September 2021 hearing, the Veteran testified that he began to have difficulty sleeping (falling and staying asleep) while deployed to Afghanistan in 2013. The Veteran testified that he sought medical treatment while deployed and was given a sleep medication to help him rest in connection with his mental health problems, but he was still fatigued during the day. Upon return from deployment, he testified that he requested a sleep study from his doctor after his wife told him that he was gasping for air in his sleep and snoring more than was usual pre-deployment. In October 2016, the Veteran's wife submitted a statement that the Veteran rarely snored before his 2013 deployment to Afghanistan, but that upon returning he snored every night and she would hear him stop breathing while he slept. She stated that before he was prescribed a breathing machine, she would sleep on the couch many nights. In August 2014, the Veteran underwent a sleep study, specifically an overnight polysomnography. The Veteran reported that he has PTSD and his sleep difficulties have worsened since deployment. The Veteran reported daytime fatigue, daily napping after work, feeling drowsy while driving, and trouble with memory and concentration. The Veteran's BMI was recorded at 29. On examination, the Veteran has micrognathia and retrognathia. Post-study, the Veteran reported he slept for 7 hours, did not remember dreaming, and felt sleepy in the morning. Intermittent, mild audible snoring was noted during the study. The Veteran was diagnosed with mild OSA with mild desaturations. OSA was seen exclusively during supine sleep, which constituted half of the total sleep time; OSA was in the severe range during supine sleep. The doctor recommended nasal CPAP titration PSG. The doctor also recommended further investigation to rule out REM sleep behavior disorder. Later in August the Veteran underwent another sleep study after receiving a BiPAP as the Veteran was intolerant of a CPAP. The doctor reported "nearly complete abolishment of apneas, hypopneas, desaturations and snoring... sleep efficiency was excellent." The Veteran's diagnosis was listed as obstructive sleep apnea. In August 2014, the Veteran was afforded a VA sleep apnea examination. The Veteran reported experiencing persistent daytime hypersomnolence and that his bed partner witnessed apnea versus hypopnea. The Veteran reported receiving a breathing machine the prior week, but that he feels "too much pressure" and "rips" the mask off. The examiner stated that he reviewed the August 2014 sleep study. The Veteran was diagnosed with mild obstructive sleep apnea with Mallampati score Class III-VI. The examiner did not offer any conclusions or opinions on whether the Veteran's sleep apnea was likely due to service. In January 2015, at a follow up visit for sleep apnea treatment, the Veteran's doctor stated the Veteran's "sleep apnea is not because of his BMI which is not excessive to begin with. His sleep apnea is caused purely by his craniofacial structure, his micrognathia and retrognathia." It was this note that was cited by the investigating officer in the line of duty determination. In June 2019, a VA opinion by the same examiner as the August 2014 exam concluded that the Veteran's obstructive sleep apnea is not caused by the Veteran's PTSD. The examiner cited several medical articles that suggested OSA may aggravate PTSD symptoms, but OSA is not caused by PTSD. This exam is inadequate because the examiner did not discuss whether OSA is aggravated by PTSD. In October 2021, the Veteran's representative submitted a positive, private nexus opinion by Dr. V.Z., who is licensed and certified in neurology and sleep medicine. The examiner stated that she reviewed the Veteran's military records, post-service treatment records, VA decisions, and lay statements. The examiner cited much of the Veteran's medical records to support her conclusion that "it is at least as likely as not that his service-connected PTSD led to the development of his OSA, and that his service-connected orthopedic condition and PTSD contributed to the development of his OSA through weight gain." Dr. V.Z. also cited numerous medical studies and articles that show a correlation between PTSD and OSA. The Board notes, however, that correlation is not causation. Additionally, the Board is aware of peer-reviewed studies that show the potential neurochemical effects of PTSD on sleep apnea and indicate a likelihood that PTSD can cause or aggravate sleep apnea by altering the chemical controllers of the musculature of the throat. See, e.g., Leszek Kubin, Neural Control of the Upper Airway: Respiratory and State-Dependent Mechanisms. Compr. Physiol. vol. 6, 4, 1801-1850 (15 Sep. 2016); Rajesh Kumar, Neural Alterations Associated with Anxiety Symptoms in Obstructive Sleep Apnea Syndrome. Depress. Anxiety vol. 26, 5, 480-91 (2009). Both studies are readily available through the National Library of Medicine (https://www.nlm.nih.gov/). Given that awareness, the relevancy of the studies, the governmental aspect of availability, and the reasonableness of locating such, the Board finds the studies to be constructively of record. See Euzebio, 989 F.3d 1305, 1321-22 (Fed. Cir. 2021). As the VA medical opinion is not adequate and has little probative value, the medical evidence of record, actual and constructive, must be found to support the claim. Furthermore, both the Veteran's statements and his wife's statements regarding the onset of his sleep apnea symptoms are competent and consistent. Their descriptions of gasping for breath in his sleep and snoring, including its onset and continuity, are not the type of statements that would require specialized knowledge to perceive or understand. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Consequently, the Board finds the Veteran and his wife's statements persuasive and highly probative. Though the Board could remand this case again for a new opinion, when considering the Veteran's PTSD and the credible statements of the Veteran and the Veteran's wife regarding his snoring, in combination with the known literature regarding causation, the Board finds that it is reasonable to conclude that the evidence supports the Veteran's claim. The Board will resolve the benefit of the doubt in favor of the Veteran and find that service connection is warranted for OSA. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. PTSD Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and, above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, 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 favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a 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 (Fed. Cir. 2007). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran's PTSD is rated under the general rating formula for mental disorders 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned for 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. A 70 percent rating is assigned for 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The U.S. Court of Appeals for the Federal Circuit has noted the "symptom-driven nature" of the General Rating Formula and 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." Vasquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed. Cir. 2013). The Federal Circuit has explained that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Id. at 117. The psychiatric symptoms listed in the above rating criteria are not exclusive but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, if the evidence shows that a veteran has symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The Veteran is seeking an initial evaluation in excess of 50 percent for PTSD. STRs indicate that in an August 2013 post-deployment exam, Veteran had been diagnosed with PTSD and panic disorder. In her October 2016 statement, the Veteran's wife stated that after the Veteran's 2013 deployment, his energy levels were low and remain low, his memory declined, and his motivation declined. In October 2016, the Veteran's co-worker and fellow National Guardsman, E.F., submitted a buddy statement relating changes that he witnessed in the Veteran after the Veteran returned from his 2013 deployment. E.F. stated that the Veteran was no able longer to participate in workouts with him as he tired very easily and quickly. E.F. also stated that the Veteran began to have trouble concentrating on single tasks and was unable to complete them. E.F. stated that the Veteran was missing deadlines at work. Another of the Veteran's co-workers and fellow National Guardsman, S.L., also submitted a buddy statement, noting that after returning from his 2013 deployment, the Veteran was unable to concentrate and could no longer discuss technical problems wand attempting to do so "created stress and confusion." His buddy also noted the Veteran was unable to "tolerate meetings or formations" without experiencing "noticeable physical distress and visible anxiety." S.L. stated the Veteran also appeared to be "lethargic" while at work. The Veteran has continuously received mental health treatment from the VA throughout the time on appeal. In October 2014, the Veteran was afforded an initial VA PTSD exam. The Veteran reported that he attends therapy twice a month and has a good relationship with his wife and friends. The Veteran reported that panic attacks started while he was deployed in Afghanistan and have continued since he returned. The Veteran reported that he had panic attacks at work. The examiner reported the Veteran was upset, had poor eye contact, was oriented, and cooperative. The examiner found the Veteran had two mental disorders: 1) PTSD with symptoms of memory problems, hypervigilance, difficulty with distressing memories, and sleep difficulty; and 2) panic disorder with symptoms of panic attacks at least weekly with intense physical symptoms. The examiner concluded both disorders create "dilemmas" to the Veteran's psychological functioning in work, family, and social life, resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. In April 2014, the Veteran's treating social worker referred the Veteran to a psychologist when he reported problems with memory function while she was treating him for panic attacks. Psychological testing revealed no memory dysfunction, mild to moderate anxiety, and panic disorder. In July 2016, the Veteran was afforded another VA PTSD examination. The Veteran reported that his relationship with his wife was "very strained," and he continued to have difficulties with crowds. The Veteran reported no other significant changes since the last exam. The examiner reported the Veteran's affect was blunted as was his mood, but his thoughts were linear, coherent, and organized; the Veteran was oriented with generally intact short- and long- term memory. The Veteran denied suicidal ideations. Testing revealed moderate anxiety and severe depression. The examiner found PTSD with delayed expression contributed to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. In November 2016, the Veteran's VA therapist noted that the Veteran was managing his anxiety "well," but he was worried about his upcoming retirement. In August 2020, the Veteran was afforded another VA PTSD examination. The Veteran reported trouble with his marriage, spending weeks away from his family at his hunting camp, feeling depressed, feeling more irritable and agitated, and having little motivation to start or finish tasks. The examiner noted that in addition to being diagnosed with PTSD, the Veteran was also diagnosed with adjustment disorder with depressed mood; however, the symptoms of the disorders and their resulting impairments overlapped, and the examiner was unable to determine their individual impact. The examiner listed the following symptoms of PTSD found in the Veteran: depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner reported that the Veteran was pleasant and cooperative, engaged well, social skills and overall presentation were adequate, hygiene and grooming were adequate, eye contact was good, speech was fluent, thought process were coherent and goal directed with no evidence of hallucinations, delusions or paranoia, affect was appropriate, and attention and concentration appeared adequate. The examiner found the Veteran experienced occupational and social impairment with reduced reliability and productivity. The examiner concluded that the Veteran's retirement in 2017 has led to a worsening of depression symptoms, diagnosing the Veteran with "an adjustment issue secondary to retirement in an individual who has already depleted emotional resources in conjunction with PTSD issues." In his September 2021 hearing, the Veteran testified that since returning from deployment he has tried to avoid crowds and confrontations, both of which trigger his panic attacks. The Veteran testified that he angers easily and will walk away from the situation when he feels angry. The Veteran testifies that he takes medication in advance of having to participate in something, for example an activity for his children, because he knows it will trigger his anxiety. The Veteran testified that news about Afghanistan also triggers his PTSD, so he avoids the news and social media. The Veteran testified that he has difficulty with impulse control and concentrating. The undersigned also notes that throughout the hearing, the Veteran was clicking a pen in a nervous and bothered manner. When asked about coping mechanisms, the Veteran testified that the pen-clicking was a possible coping mechanism in addition to bouncing his knee during the hearing. In November 2021, the Veteran was afforded another VA PTSD examination. The Veteran reported he had limited friendships and trouble in all of his relationships. The Veteran reported that he felt like his medication was not "doing that much" for him. He denied hospitalizations and suicidal ideations, but "he did not care if he lived or died." The examiner reported the Veteran was alert and oriented to person, place, and time; was adequately groomed; no evidence of psychomotor disturbance; mood and affect were depressed; no evidence of thought disordered or delusional thinking; insight was present; and judgment and impulse control appeared adequate. The examiner listed the following symptoms of PTSD found in the Veteran: depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, inability to establish and maintain effective relationships, and irritability without physical violence. The examiner found that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood. Based on the Veteran's overall symptomatology and the resulting impairment stemming therefrom, the Board finds that the disability picture presented throughout the period on appeal most closely approximates the level of severity contemplated by the current 50 percent rating for PTSD. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. All the VA examiners, in October 2014, July 2016, August 2020, and November 2021, noted the Veteran's symptoms of depressed mood, anxiety, suspiciousness, and disturbances in motivation and mood. Additionally, buddy statements from the Veteran's wife and friends related examples of witnessing the Veteran display symptoms of fatigue, lack of motivation, and trouble concentrating. The medical evidence of record does not indicate that the Veteran experienced suicidal ideation, obsessional rituals which interfered 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; or an inability to establish and maintain effective relationships during this time period. While there is some evidence of a slight worsening of the Veteran's symptoms at times, for example, increasing irritability with no violence, the record indicates the Veteran was able to walk away from the situation and retained some coping mechanisms. He showed good judgement and awareness. While he had some behaviors like pen clicking and knee movement when stressed, such did not interfere with his ability to function. There is no indication in the medical records that his symptoms were severe enough to cause occupational and social impairment with deficiencies in most areas; therefore, a 70 percent rating, or higher, is not warranted. Considering the record as a whole, the Veteran's deficiencies due to his PTSD more closely approximates the 50 percent rating. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; the weight of the evidence is persuasively against the Veteran's claim, and the doctrine is not applicable. 38 U.S.C. § 5107(b). 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. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." See 38 C.F.R. §§ 3.340 (a)(1), 4.15. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) 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). 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). The issue is not whether the Veteran can find employment generally, but whether the Veteran is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (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. The Veteran testified that his last day of work was October 31, 2017, and that he was forced to retire because his civilian job required him to be in the Guard, which he was not able to continue due to service-connected disabilities. Since stopping work, the Veteran has met the threshold schedular criteria for TDIU. 38 C.F.R. § 4.16(a). The Veteran's PTSD has been rated 50 percent disabling since October 19, 2013; lower back strain with traumatic arthritis has been rated 20 percent disabling since October 19, 2013; the Veteran's left shoulder injury has been rated 20 percent disabling since June 27, 2016; the Veteran's neck injury with radiculopathy has been rated 20 percent disabling since June 27, 2016; the Veteran's right hip and left hip pain syndrome have each been rated 10 percent disabling since October 19, 2013; the Veteran's tinnitus has been rated 10 percent disabling since June 27, 2016; the Veteran's degenerative disc disease of the cervical spine has been rated 10 percent disabling since August 9, 2016; and the Veteran's fibromyalgia has been rated 10 percent disabling since December 27, 2016. The Veteran's combined disability was 80 percent disabling since October 19, 2013, and increased to 90 percent disabling since June 27, 2016. The Veteran testified that he graduated from high school and took some college courses. The Veteran testified that his previous work as a mechanic required him to move about and contort his body, which he is unable to do because of his shoulder and neck conditions. The Veteran also testified that he had difficulty interacting with his co-workers and was unable to concentrate on even simple tasks, despite being responsible for complicated, technical tasks. In his October 2016 statement, the Veteran's co-worker S.L. reported that he noticed the Veteran's shoulder injury physically limited the Veteran. Through his representative, the Veteran submitted a vocational opinion by a certified vocational evaluator. The evaluator stated that they interviewed the Veteran, reviewed the Veteran's claims file, and considered only the Veteran's service-connected disabilities in their opinion. The evaluator opined that although the Veteran graduated high school, and completed some college courses, "the combination of the Veteran's service-connected intrusive psychological symptoms, fatigue from chronic sleep impairment, physical pain, and subsequent limitations in concentration erode any transferable skills he acquired throughout his vocational history. The Veteran is unable to retain or execute any past transferable skills due to significant difficulty in maintaining concentration, and subsequent difficulty completing complex tasks. In addition, his service-connected PTSD symptoms and pain from his service-connected physical conditions negatively impact his ability to learn new skills due to impairments in concentration... He does not have any computer training which would give him any type of advantage in sedentary work." Based on the evidence of record, and resolving all doubt in favor of the Veteran, the Board finds that the Veteran's service-connected disabilities preclude him from maintaining substantially gainful employment that is consistent with his education and occupational experience, beginning November 1, 2017. In this regard, the Veteran had been employed as an aircraft maintenance supervisor. The Veteran is precluded from even light manual work due to his service-connected physical disabilities of the hip, shoulder, and neck. These prevent him from prolonged standing, walking, reaching, and climbing. The Veteran is precluded from more sedentary, less physical work, such as in an office, due to his service-connected PTSD and OSA, which prevent him retaining or executing any past transferable skills, maintaining concentration, completing complex tasks, and interacting with others. In light of the above evidence, the Board finds that the Veteran is not capable of substantially gainful employment due to his service-connected disabilities as of November 1, 2017, the day after his last day of employment. Accordingly, TDIU is warranted. Moreover, even in light of the TDIU grant, consideration of special monthly compensation entitlement is not required, as there is no single disability rated totally disabling. Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lauren Barletta 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.