Citation Nr: A24081663 Decision Date: 12/09/24 Archive Date: 12/09/24 DOCKET NO. 211115-197818 DATE: December 9, 2024 ORDER Entitlement to an increased rating of 70 percent, but not higher, for posttraumatic stress disorder (PTSD) on and after January 29, 2020, is granted. Entitlement to an effective date of September 24, 2018, for a total disability rating based on individual unemployment (TDIU) is granted. FINDINGS OF FACT 1. On and after January 29, 2020, the Veteran's PTSD manifested with occupational and social impairment with deficiencies in most areas, but without total occupational and social impairment. 2. The Veteran is service connected for: 1) PTSD, rated at 70 percent; 2) chondromalacia patella of the left knee, rated at 10 percent on and from June 10, 2011; 3) degenerative disc disease of the thoracolumbar spine, rated at 40 percent on and from May 3, 2021; 4) -5) right and left lower extremity femoral nerve radiculopathy, rated at 20 percent on and from May 3, 2021; 6) allergic rhinitis rated noncompensable on and from November 19, 2021; 7) tinnitus, rated at 10 percent on and from May 8, 2024. 3. During the appeal period, the Veteran's combined ratings is 70 percent prior to May 3, 2021; 80 percent on and after May 3, 2021, and is in receipt of a TDIU on and after May 3, 2021. 4. On and from September 24, 2018, the Veteran's service-connected disabilities rendered him unable to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating of 70 percent, but not higher, for PTSD on and after January 29, 2020, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to an effective date of September 24, 2018, for a TDIU are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.15, 4.16, 4.18. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran honorably served on active duty in the United States Army from May 2007 to April 2008, and from June 2008 to June 2011. See DD Form 10182. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2021 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), in pertinent part denying a rating in excess of 50 percent for PTSD on and from January 28, 2020. Notably, in July 2021, the Board granted an increased rating of 70 percent for PTSD from September 24, 2018, to January 28, 2020. See July 2021 BVA Decision. Therefore, the portion of the July 2021 rating decision implementing the July 2021 Board grant of an increased rating for PTSD of 70 percent, but not higher, from September 24, 2018, to January 28, 2020, cannot be appealed as the RO did not have the authority to assign a rating contrary to the Board's order and was required to simply implement the Board decision. See Smith v. Brown, 35 F.3d 1516, 1526 (Fed. Cir. 1994) (recognizing VA's administrative (RO)-judicial (BVA, appellate) review scheme, which does not permit an inferior adjudicatory tribunal to collaterally review the actions of a superior appellate tribunal). Moreover, during the pendency of the appeal, a November 2021 rating decision granted a TDIU on and from May 3, 2021. In November 2021, the Veteran appealed the denial of a rating for PTSD in excess of 50 percent after January 28, 2020, and the effective date for the award of a TDIU, prior to May 31, 2021, and selected the direct review docket. See November 2021 VA Form 10182. APPLICABLE EVIDENTIARY WINDOW As the appellant has selected the Direct Review Docket, the Board may only consider the evidence of record before the AOJ at the time of its decision on the issue(s) on appeal. See 38 C.F.R. §§ 20.300(a), 301. The Board will not consider evidence received after the AOJ decision unless the claimant files a timely request for a Board hearing or an opportunity to submit additional evidence on the NOD (VA Form 10182). 38 C.F.R. § 20.301. The appellant has not filed such a request. If additional evidence was submitted after the AOJ decision, the Board will not consider it. The appellant is welcome to file a supplemental claim to have this evidence considered. See Cook v. McDonough, 36 Vet. App. 175 (2023). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Individual disabilities are assigned separate diagnostic codes. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. See Vazquez-Claudio, 713 F.3d at 118. In this regard, the General Rating Formula For Mental Disorders provides a 50 percent is assigned when symptoms such 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 and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.130. A 70 percent evaluation is assigned when a veteran's psychiatric disorder causes 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 an inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent rating is assigned when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. 1. Entitlement to an increased rating of 70 percent, but not higher, for PTSD on and after January 29, 2020, is granted. The Veteran asserted that on and after January 29, 2020, the severity of his psychiatric symptoms more nearly approximates that of a 70 percent evaluation, and that the RO should not have reduced the Veteran's rating from 70 percent to 50 percent. See November 2021 VA Form 10182. Notably, the July 2021 Board decision limited the grant of an increased rating from 50 to 70 percent to the period going from September 24, 2018, to January 28, 2020. Furthermore, prior to the July 2021 Board decision granting an increased rating of 70 percent, the Veteran's PTSD was already rated at 50 percent. In the case of a staged rating involving the simultaneous assignment in a rating decision of higher and lower evaluations for a disorder, there is no reduction of a rating unless the rating action assigns a disability evaluation which is below that level previously in existence. See O'Connell v. Nicholson, 21 Vet. App. 89, 92 n.3 (2007). Here, the stages were assigned by the RO simultaneously, and the Veteran's PTSD was already rated at 50 percent prior to his increased rating claim. Therefore, the disability rating was not reduced below the 50 percent rating in any given moment. Thus, the assignment of a 50 percent rating on and from January 28, 2020, does not constitute a reduction of an existing rating. Therefore, the issue before the Board is entitlement to an increased rating for PTSD, and the regulatory provisions for rating reductions are not applicable. With respect to the medical evidence, the Veteran was afforded a VA examination in March 2020 and March 2021. It is unclear whether the March 2020 VA examination was conducted in person, via telehealth, or was based on a review of the claims file. At any rate, during the examination, the VA examiner discussed with the Veteran his social, marital and family history. Id. Specifically, the Veteran reported living with his mother and grandmother, being married and divorced twice, having two daughters but being in contact with only one of them, who he sees during visitations. See March 2020 VA Examination Report. The Veteran denied having any hobbies or interests, and endorsed depressed mood, social withdrawal, anxiety, suspiciousness, panic attacks more than once a week, and chronic sleep impairment. Id. Based on his observation, the VA examiner indicated that the Veteran appeared oriented in all spheres, alert, cooperative, polite and cordial, and maintained steady eye contact, no problems with concentration or attention were noted, his speech was within normal limit for rate, volume, and fluency, his thoughts were logical, organized, and without evidence of thought disorder, his insight and judgment were intact, and he did not appear to pose any threat of danger or injury to self or others. Id. However, the VA examiner noted the Veteran displayed poor hygiene, and was not properly dressed and groomed. Id. With respect to his occupational and educational history, the VA examiner noted that after high school, the Veteran held various jobs, to include for Budget Rent-A-Car, from 1999 to 2000, and while he attempted to go to community college, he ultimately stayed home and took care of his grandparents until he joined the National Guards. Id. After his active service, he worked for Casey Gas Station in 2017, for a total of nine months, until he quit because of his mood and anger issues. Id. The Veteran has been unemployed since. In March 2021, the Veteran was afforded a new VA examination via video telehealth, at which time the Veteran denied a history of psychiatric hospitalizations or suicide attempts since his previous VA examination and endorsed a history of attendance in psychotherapy with Dr. C.B., and Dr. C. See March 2021 VA Examination Report. The Veteran reported living "day by day," watching tv or surfing the internet during his free time and keeping in touch with his "battle buddy" and other friends via social media. Id. The Veteran endorsed a history of gambling before the Covid-19 pandemic, although he made some statements suggesting that he continued gambling afterwards. Id. He reported "white lights and ringing in my ear make me angry," admitted having difficulties falling asleep and staying asleep for more than five hours due to frequent nightmares about his military service. Id. He also reported he is diagnosed with sleep apnea and has been issued a CPAP but does not wear it at night. Id. The Veteran also reported some obsessional rituals. For example, when driving he takes different routes to avoid the possibility of people following him. Id. He also endorsed being occasionally irate with his mother and yelling at her but denied physical aggression. Id. Furthermore, while the veteran denied symptoms of suicidal ideations, homicidal ideations, and auditory or visual hallucinations during the visit, he also stated: "If I didn't have my daughter I wouldn't be here." Id. Based on her observation, the VA examiner indicated that the Veteran was alert and oriented in all spheres, cooperative, adequately groomed, and appropriately dressed for the weather, his speech was spontaneous and clear, thought process fluid and goal directed. Id. The Veteran did not appear to pose any threat of danger or injury to self or others. Id. Between February 2020 and March 2020, the Veteran was seeing social worker K.S. See May 2021 Capri Record. In February 2020, Ms. K.S. found the Veteran's mood to be stable, although he was reporting difficulties with sleep and being in public, dizziness, trust issues, difficulty in relationships, past gambling problems, mood swings, anxiety, poor communication with others, and difficulty with focus/concentration as his evidence that he is unable to work. Id. Ms. K.S. then noted "Veteran may very well be experiencing these symptoms and issues, but therapist is going to discharge veteran if he is not wanting to work on his problems and participate in therapy. At this point, these visits reflect only his determination to develop his claim as opposed to wanting to get better." Id. Similarly, during a March 2020 mental health appointment, Ms. K.S. noted: "Took the time to explain in detail again today that veteran's attendance in therapy is not necessarily a way to prove that he sees his symptoms as increasingly worse. Therapist said she notes any symptoms reported by vet, but there is nothing to indicate that symptoms are worse now than they had been a few weeks ago. Therapist said veteran has been mostly isolated and unemployed for a few years. He has always reported nightmares and intrusions in the same way he currently does, so there is no evidence to say everything is worse. The same level of problems ha[s] been reported by veteran for several years. Veteran is requesting new therapist so referral will be made to Marion." Id. A follow-up note the next day also reads: "Veteran is interested in talking with a new therapist. His agenda has been to build a case for himself to increase SC and not with therapy per se. Therapist has processed several times with patient that therapy and SC claims can be contrasting efforts as therapist is trying to help improve the symptoms and veteran is wanting to prove they are worse. Veteran is interested in talking to another therapist and may need someone else to reinforce the purpose of therapy versus efforts with VBA." Id. After he stopped seeing Ms. K.S., in March 2020, the Veteran started to see a new therapist, C.B., a licensed professional counselor. Id. During his sessions with his new therapist, Ms. C.B. noted that the Veteran was feeling constantly alert, feeling down, anxious, paranoid, irritable, had difficulty trusting people, was experiencing sleeping difficulties with nightmares and anhedonia, had some hallucinations, also characterized as day dreaming, and panic attacks. Id. His personal hygiene and grooming were good, he was appropriately dressed for setting and season, mood was euthymic and affect was congruent with mood, was oriented to time, place and situation, his thought process was linear and the content of his speech was goal-directed and coherent, his insight and judgment were good, speech was normal for tone, volume and rate, eye contact was good, there were no indications of perceptual disturbances. Id. However, during the suicide prevention screening, the Veteran admitted that he wished he were dead or could go to sleep and not wake up, and endorsed over the previous month that he had actual thoughts of killing himself. Id. The following session in March 2020 recorded similar behavioral observations and mental status, but interestingly the Veteran also reported: "I am kind of stuck, I want help, but I also need my SC increased to help me. I fought for this country, witnessed many traumatic things and they owe me." Id. In June 2020, the Veteran denied suicidal ideations, homicidal ideations, and any type of hallucinations, but identified that he has experienced relapse and recovery regarding alcohol and gambling. Id. In July 2020, the Veteran continued to report similar symptoms, but with an increase in sleeping disturbances, and discussed his fear of fireworks and his concerns with the upcoming 4th of July celebration. Id. Furthermore, the Veteran endorsed some violent behavior at home, but limited to throwing objects. Id. While the therapist's behavioral observations of the Veteran were the same, she noted that the Veteran had not been able to come to terms emotionally with traumatic events, as evidenced by anger, hallucinations, daydreaming, panic attacks, anxiety, sleep difficulties, suicidal ideations/thoughts. Id. In July 2020, the Veteran was seen by Dr. C., a licensed psychiatrist, who noted the Veteran reported continued issues with anger, depression, and anxiety, and that he has had suicidal thoughts chronically without plans. Id. Again the Veteran appeared oriented in all spheres, was appropriately dressed and groomed, displayed good eye contact, was cooperative, his mood was euthymic with no evidence of agitation, anxiety, or lability, affect was consistent with mood, speech was unremarkable, with normal rate, tone, articulation and volume, memory for remote, recent, and immediate information was intact, based on his ability to provide history, thought process was linear and logic, his attention span and concentration normal, judgment was adequate, insight fair, language normal, and there was no evidence of psychosis. Id. In August 2020, the Veteran was seen weekly by his therapist, C.B., who noted the Veteran's struggle with mislaying thoughts and emotions and discussed his financial concerns. Id. When asked about his reported hallucinations, the Veteran stated: "I'll start thinking about IRAQ then I kind of go into a trance and I feel gone for a while. Sometimes it's a smell that starts me thinking about Iraq again." Id. The Veteran also stated that he does not hear voices and indicated he was unsure as to whether they were actual hallucinations or thoughts. Id. Finally, the treatment note reported that the Veteran "always has passing thoughts of S[uicidal] I[deations] but never a plan" indicating that he loves his family, which is his strongest protective factor. Id. In September 2020, Ms. C.B. noted that the Veteran reported his symptoms were causing severe difficulties on his emotional and behavioral functioning and endorsed anhedonia. Id. The Veteran's symptoms and behavioral observations were similar to those of previous treatment notes, but the Veteran requested to be discharged because he could no longer manage going to therapy while helping his daughter with remote learning. Id. Between February and March 2021, the Veteran reported that an increase in medication dosage improved his sleep, resulting in an additional hour of sleep at night. Id. In May 2021, however, the Veteran reported daily auditory and visual hallucinations about his time in Iraq, and daily passive suicidal ideations, without intent or plan, with his daughter being the strongest protective factor. Id. In April 2021, the Veteran also submitted a private mental health evaluation by a private psychologist. See April 2021 Private Treatment Record. The private examiner noted that the Veteran's current symptomatology included episodes of depression, increased anger, irritability, trouble coping with stress or emotions, low motivation and energy, poor hygiene, suicidal ideations at least once a month, anxiety, hypervigilance, sleep impairment with nightmares, memory disturbances to include inability to remember to complete tasks, hypervigilance, obsessional rituals to include monitoring and assessing place and situations for threats and thinking about a contingency plan, attention and concentration difficulties, social isolation, impaired impulse control with episodes of non-physical violence and gambling, and difficulty adapting to stressful circumstances. Id. The private examiner also explained that the Veteran had been unemployed since 2018, when he last worked at a gas station doing inventory, and that when he was moved to cashiering, the Veteran started to feel hypervigilant, irritable, and overwhelmed as he struggled with the interactions with the public and started to become irritable when around other people. Id. Based on the severity of the Veteran's psychiatric symptoms, the private examiner opined that the Veteran's occupational impairment prevents him from securing or following substantially gainful employment. Id. Most importantly, the private examiner addressed the conflicting medical evidence, namely that the Veteran inconsistently reported some of his subjective symptoms, and concerns that the Veteran was using his therapy sessions to build evidence for his claims for disability benefits. Id. With respect to the inconsistent reporting of subjective symptoms, the private examiner indicated that this can sometimes be explained by inability to understand and respond to a question, excessive fatigue or poor concentration, cognitive or intellectual deficits, distress, a cry for help, or severe psychopathology and maladjustment, and that it is not automatically synonymous of overt secondary gain. Id. Moreover, the private examiner indicated that malingering can be screened and assessed by medical professionals, and that in January 2019, a licensed psychologist, Dr. D., administered the Personality Assessment Inventory (PAI) and the Clinical Multiaxial Inventory -III (MCMI 3) test, to measure atypical response profiles suggestive of possible exaggeration of symptoms. Id. Dr. D. noted that Overt malingering scales were not positive and concluded that the Veteran's response style across both measures were more consistent with a "cry for help" response set. Id. In light of the above, the private examiner concluded that the Veteran was a credible historian. Moreover, the private examiner discussed the Veteran's inconsistent reporting of suicidal ideations between private and VA providers between 2018 and 2020. Id. First, the private examiner emphasized how difficult and traumatic reporting and discussing suicidal ideations can be for a patient, especially in this case where the treatment notes suggest that the Veteran has been reluctant and has repressed his emotions and problems for years. Id. Moreover, the private examiner highlighted that the Veteran reported suicidal ideations throughout the appeal period. With respect to the claim that the Veteran used therapy for overt gain, i.e., to build a case for his disability benefits claim, the private examiner noted that during therapy, patients are told to discuss anything with their therapist, and they often seek assistance from VA therapists for housing, vocational rehabilitation, and the like. Id. Additionally, while the private examiner warned of the dangers of cherry-picking quotes or clinical note outside of context, he highlighted some evidence that shows the Veteran was not primarily focused on disability benefits. Specifically, in June 2019, VA social worker, Ms. K.S., documented: "it is true that the Veteran is focused on getting SC for mental health issues, but when this provider carefully broke down the assessment criteria for PTSD in terms veteran could better understand, it seemed evident that he was providing genuine responses that corroborate the presence of consistent PTSD symptoms. He has been exposed to life threatening events and witnessed death and destruction, and these are the things the veteran remains reactive to. He does not like discussing these topics and therapist doubts that veteran will stay in therapy much longer. He seems wise beyond his years in some ways, but his overall presentation suggests immaturity. Dr. [D.]'s January 2019 psychological evaluation noted very similar issues, but also suggested these things could be veteran's "cry for help" Therapist believes Dr. [D.] was on target with that suggestion" Id. Similarly, the private examiner highlighted an April 2020 treatment note from a therapy session with the licensed professional counselor, Ms. C.B., at which time she asked the Veteran how losing confidence in the disability benefit process had interfered with his treatment, and the Veteran replied that he was not sure. Id. Overall, the private examiner highlighted evidence suggesting that the Veteran's primary topic of discussion was not his disability claim, but rather engaging in therapy to improve his symptoms and reduce their functional impairment. As noted above, with respect to his employment history, the Veteran indicated that after he stopped working at Casey Gas Station in April 2018, he remained unemployed. See, e.g., September 2021 VA Form 21-8940. The Board finds the April 2021 private examination to be of high probative value, considering that the private examiner thoroughly assessed the Veteran's symptoms, and the conflicting medical evidence. On the contrary, the Board finds that the March 2020 and March 2021 VA examinations to have lower probative value as they did not reflect a thorough review of the claims file and did not sufficiently discuss the conflicting medical evidence. The Board acknowledges the Veteran's symptoms and finds that on and from January 29, 2020, their severity, frequency, and duration more closely approximate the symptoms contemplated by a 70 percent rating. In that regard, his psychiatric disability was largely characterized by near-continuous depression affecting the ability to function independently, appropriately, and effectively, anxiety, social isolation, chronic sleep impairment, anhedonia, suspiciousness, paranoia, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationship, difficulty adapting to stressful circumstances, including work or work-like settings, impaired impulse control, such as unprovoked irritability and gambling habits, and chronic passive suicidal ideations. On and from January 29, 2020, the various examiners noted that he did not exhibit gross impairment in thought processes and communication, was able to properly communicate, was alert and oriented to person, place, time, and situations, his responses to examiners were clear and coherent, his thought content was unremarkable although paranoid and circumstantial at times, he presented himself as properly groomed and capable of performing activities of daily living and denied delusions, inpatient hospitalizations, psychotic episodes, inappropriate, obsessive or ritualistic behaviors, while reporting occasional visual or auditory hallucinations which the Veteran himself was unsure as to whether they were hallucinations, daydreaming, or just thoughts. Moreover, while the Veteran presented poor hygiene on one occasion, the Board finds that it did not result in an inability to perform activities of daily living. At no point in time his VA or private therapist or a VA examiner found him to be a persistent danger for himself or others. By extension, the Board finds that on and from January 29, 2020, the Veteran had also retained some social functioning in that he reported keeping in touch with some old friends via social media, taking case of his daughter during visitation, and helping her with her distance learning, and having a good relationship with his grandmother and mother. Since the Veteran was unemployed during the appeal period, the impact of his disability on his work relationships was not discussed during the VA examination or during his encounter with his private psychologist. Overall, the evidence demonstrates that even though his PTSD and unspecified depressive disorder impaired his occupational and social skills on and from January 29, 2020, the Veteran was still able to function in these areas, although with deficiencies. For all these reasons, the Veteran's disability picture, as a whole, more nearly approximate occupational and social impairment with deficiencies in most areas on and from January 29, 2020. Notably, the Veteran was already awarded a 70 percent increase for PTSD from September 24, 2018, to January 28, 2020. Accordingly, entitlement to an increased rating of 70 percent, but not higher, for PTSD on and from January 28, 2020, is granted. 2. Entitlement to an effective date of September 24, 2018, for a TDIU is granted. The Veteran contends that the effective date for his award of a TDIU should be April 9, 2018, the date that he became too disabled to work, and not May 3, 2021. See, e.g., November 2021 VA Form 10182. A total disability rating based on unemployability may be assigned where the schedular rating is less than total and the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. In order for the Veteran to meet the schedular criteria for entitlement to TDIU, if there is only one service-connected disability, such disability shall be ratable as 60 percent or more, and if there are two or more service-connected disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Here, from June 10, 2011, to September 24, 2018, the Veteran is service connected only for a left knee chondromalacia patella rated as 10 percent disabling. By virtue of this decision, the Veteran has a 70 percent rating for his psychiatric disability on and from September 24, 2018, with a combined rating of 70 percent. Consequently, the Veteran meets the schedular criteria for a TDIU on and from September 24, 2018, but not earlier. While the general rating schedule is based on the "average impairment in earning capacity caused by a disability," entitlement to TDIU is based on the individual's particular circumstances. Thun v. Peake, 22 Vet. App. 111, 116 (2008), and Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). A claim for a total disability rating based upon individual unemployability asks for TDIU because of 'subjective' factors, to include the Veteran's education, training, and work history, that the 'objective' rating does not consider. See Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In determining whether a veteran can secure and follow a substantially gainful occupation, term "unable to secure and follow a substantially gainful occupation" is defined in § 4.16(b) to include two components: one economic and one noneconomic. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The non-economic component includes consideration of the veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue, provided that discussion of any factor is only necessary if the evidence raises it. Id. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to secure or follow employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Additionally, the central inquiry in determining entitlement to a TDIU is whether service-connected disabilities alone are of sufficient severity to produce unemployability. See Hatlestad v. Brown, 5 Vet. App. 524 (1993). The ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator. 38 C.F.R. § 4.16(a); See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Here, the Veteran contends that based on the nature and severity of his symptoms, particularly anger issues, he had to leave his job on April 9, 2018, and was unable to follow or secure substantial gainful employment since. See February 2020 VA Form 21-8940. As a background, the Veteran has a high-school level of education. See March 2020 Medical Treatment Records Furnished by SSA. During a private examination in April 2021, the Veteran discussed his employment history after high school and prior to service, which includes working as a warehouse, at Taco Bell, at Pizza Hut, at Jack in the Box, then for a moving company, and finally for a car rental agency. See April 2021 Private Treatment Record. After service, he worked for a tire factory building tires, as a carrier for USPS, and then at a gas station for 9 months, first doing inventory and then at the cashier. Id; see also March 2020 Medical Treatment Records Furnished by SSA. When at the gas station he was moved to the cashier, the Veteran indicated that he started to feel hypervigilant, irritable, and overwhelmed, as he struggled with social interaction and dealing with customers and quit. Id. During a December 2018 private examination, the private examiner noted that the Veteran was self-employed in the recycling business. See January 2019 Private Treatment Record. During an April 2019 mental health outpatient appointment, the Veteran specified that he has some income from recycling cans, and that he would like to develop a business that could possibly help other veterans. See June 2020 Capri Record. With respect to the income from the recycling business, the Veteran indicated that his income was approximately $40,000 per year on average. See March 2020 Medical Treatment Records Furnished by SSA. As indicated above, the term "unable to secure and follow a substantially gainful occupation" is defined in § 4.16(b) as to include two components: one economic and one noneconomic. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component means an occupation earning more than marginal income determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. In this case, the Board finds that the income from the recycling business to be marginal income, and therefore does not preclude an award of a TDIU. During a September 2019 VA examination for his left knee disability, the Veteran reported that he cannot tolerate standing for long periods, his legs fall asleep after sitting for a while, picking heavy objects increases his pain, cannot climb ladders or stairs, and cannot kneel or squat without having excruciating pain. See September 2019 VA Examination Report. Id. The VA examiner opined that the disability impacts the Veteran's ability to perform any type of occupational task, to include standing, walking, lifting and sitting, and that in a 12-months span, he would lose 2 to 4 weeks of work time on average. Id. During a December 2019 mental health visit, the Veteran indicated that he did not want to leave the house or go to work because he "doesn't tolerate others and wants to avoid people." See June 2020 Capri Record. The Veteran reported having anxiety and at least one "panic attack" weekly, feeling his heart pounding/racing, and experiencing breathing difficulties, broken sleep and insomnia. Id. Veteran noted his feelings were so intense "I can barely stand it." Id. Veteran admitted to anhedonia, and anergia, and poor hygiene, except when he had a scheduled medical appointment. Id. Furthermore, the therapist reported that the Veteran believes he is not able to perform adequately in a job based on his difficulties being around others, particularly strangers, and his conflict issues, and reported feeling "lost" at times. Id. Therapist inquired as to whether veteran wanted to try to get better, but the Veteran responded he was unsure as to whether he is capable of doing what he needs to do to care for himself. Id. Notably, in the Veteran's SSA disability application, his mother indicated that she observed the Veteran having issues with anger, hopelessness, depression, paranoia, insomnia with nightmares, as well as knees and back problems. See Mach 2020 Medical Treatment Records Furnished by SSA. The Veteran's mother shared that the Veteran spends his time home and goes outside with his car once a week. Id. The Veteran indicated, and his mother confirmed, that when he drives, he takes different routes, is always anxious about having people driving around him, is constantly checking his surroundings and scanning for IEDs. Id. The Veteran's mother reported that the Veteran prefers being by himself, does not have friends, or a social circle and was only attending church every two weeks. Id. The Veteran, however, endorsed going on walks in the morning. Id. In July 2021, the Board had already found that from September 24, 2018, to January 27, 2020, the Veteran's PTSD caused occupational and social impairment with deficiencies in most areas, to include work. With this decision, the Board finds that on and after January 28, 2020, the Veteran's PTSD caused occupational and social impairment with deficiencies in most areas, to include work. During this time, the Veteran's symptoms manifested with near continuous depressed mood affecting the ability to function, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, flattened affect, social isolation, difficulty in understanding complex commands, impaired judgment, 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, obsessional rituals which interfere with routine activities, impaired impulse control, such as unprovoked irritability with periods of violence and gambling. The April 2021 private examiner opined that the Veteran's psychiatric symptoms rendered him unemployable. See April 2021 Private Treatment Record. In that regard, the Veteran's has a high-school education, and worked various jobs in customer-facing capacity, as well as tire builder, mail carrier, employee for a moving company, and doing inventory and cashiering for a gas station. No other formal training was evidenced in the claims file. As a result, the Board finds that obtaining sedentary employment is not consistent with his educational, occupational history, and physical and mental abilities. Taken as a whole, the Veteran's psychiatric and physical symptoms suggest he was unable to obtain and/or maintain employment throughout the appeal period consistent with his employment history and education. Given the Veteran's education and work history, symptoms reported by the Veteran and others, and the level of functional impairment as reported by VA examiners and treatment providers, the Board considers this level of impairment as one that would preclude employment in the Veteran's chosen field. The evidence of record shows that the Veteran does not have the physical and mental ability to perform the type of activities required by the occupations the Veteran is qualified for. Ray, 31 Vet. App. at 73. Based on the above medical and lay evidence with respect to his psychiatric and physical symptoms, the Board finds that the severity of his service connected disabilities rendered him unable to secure and follow gainful employment from on and from September 24, 2018. As the evidence suggests that the Veteran is unable to maintain a substantially gainful occupation, and he is already in receipt of a TDIU on and from May 3, 2021, the Board concludes that an earlier effective date of September 24, 2018, for the award of a TDIU is warranted. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Fiorito, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.