Citation Nr: 24010474 Decision Date: 03/05/24 Archive Date: 03/05/24 DOCKET NO. 15-46 262 DATE: March 5, 2024 ORDER Entitlement to a rating in excess of 70 percent disabling for post-traumatic stress disorder (PTSD) for the appeal period prior to March 8, 2022, remains denied. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disability for the appeal period prior to March 8, 2022, is granted. FINDINGS OF FACT 1. For the appeal period prior to March 8, 2022, the Veteran's PTSD symptoms do not result in total occupational and social impairment. 2. For the appeal period prior to March 8, 2022, the Veteran's service-connected PTSD symptoms render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for PTSD have not been met for the appeal period prior to March 8, 2022. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The issue of entitlement to a TDIU is granted for the appeal period prior to March 8, 2022. 38 U.S.C. §§ 1114, 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service in the Army from March 1964 to April 1985. This appeal comes to the Board of Veterans' Appeals (Board) from a May 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office in Nashville, Tennessee. The Board remanded this matter for additional development in remands dated in June 2019 and October 2022. Such has been completed and this matter is returned to the Board for additional consideration. In January 2019, the Veteran testified at a travel board hearing before a Veterans Law Judge who has since left the Board. He testified again before the undersigned Veterans Law Judge at a hearing held in June 2022. Transcripts of these hearings are associated with the claims folder. The Board notes that additional records were added to the claims folder after the most recent RO adjudication in a June 2023 supplemental statement of the case (SSOC). The appeal was returned to the Board with docketing letters sent to the Veteran in July 2023. Pursuant to 38 C.F.R. § 19.31, SSOC's are furnished when the agency of original jurisdiction (AOJ) receives additional pertinent evidence after an SOC or the most recent SSOC has been issued and before the appeal is certified to the Board. In this matter the records received after the June 2023 SSOC were after the appeal was certified and returned to the Board. Additionally, the pertinent evidence received was either duplicative of the evidence previously adjudicated or was outside the appeal period in this matter. Therefore, it is not necessary to remand this matter to obtain a SSOC. 1. Rating in excess of 70 percent disabling for PTSD. The Veteran contends that his PTSD symptoms are more severe than currently evaluated. At his January 2019 hearing before a different Veteran's Law Judge (VLJ) he testified that his symptoms have worsened since 2012 and that his anxiety and night terrors have worsened. He reported increased difficulty in crowds and that his flashbacks have increased. He described his night terrors as waking him up every night. His fiancée testified that he wakes up screaming and sometimes striking out about 4 times a night and sometimes falls on the floor during such episodes. He testified that when he was awake, he did not remember the night terror incidents. His representative indicated that the Veteran's two main issues were anxiety and night terrors. The Veteran testified that he has hypervigilance and is always looking around for possible threats. He also described avoidance of anxious situations and indicated that he stopped working as at a state penitentiary in 2008 due to anxiety. He also reported issues with anger and had to attend anger management classes. His fiancée described issues he had with anxiety while shopping or other situations in crowds where she helped keep him calm by holding his hand, and that once he left a full shopping cart in the store due to anxiety. Transcript 1/19 hearing pg. 4-8, 11-15, 20-22. In his subsequent hearing held in June 2022, the Veteran primarily testified about his current PTSD symptoms and their impact on his social and occupational functioning. He described his symptoms including anxiety and panic attacks as keeping him isolated from others outside of his family and being unable to go to stores. He described continued issues with nightmares and described night terrors as interrupting his sleep patterns. He described no longer participating in activities he used to enjoy such as fishing and bowling due to PTSD symptoms. The Board notes that his hearing testimony came during a period where a 100 percent schedular rating is in effect. Transcript 6/22 hearing pg. 4-6, 9. Most recently, the Veteran testified in November 2023, indicating that since 2011 he had trouble leaving his house due to anxiety. He also described sleep disturbances, trust issues, and social isolation. He also reported panic attacks and nightmares during the period in question. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating 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. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale, and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in June 2020. As such, the DSM-5 applies, and the GAF scores will not be considered. The question is whether the evidence supports a rating in excess of 70 percent prior to date for PTSD for the appeal period prior to March 8, 2022. After the Veteran filed the January 24, 2012, claim on appeal, he underwent a VA examination in March 2012. The lone diagnosis was of PTSD, chronic, and he was found to meet the diagnostic criteria for PTSD. This diagnosed disorder resulted in occupational and social impairment with deficiencies in most areas such as work school family relations judgment thinking and/or mood. He reported being married to his first wife for 42 years and described relationship as "great," adding that his wife has put up with a lot regarding his night terrors, including his hitting her in his sleep and irritability. He said he sleeps on the couch now. He described good relationship with younger daughter and "on and off" with his other daughter, which he attributed to her personality rather than his issues. He reported having one close friend, a neighbor he talked to "once in a while" and denied having other friends. He denied a legal history since his last exam. He denied using ETOH or illicit drugs since August 2008. The Veteran reported symptoms of anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, and mild memory loss such as forgetting names, directions, or recent events. He had impairment of short- and long-term memory for example retention of only highly learned materials, while forgetting to complete tasks. He had disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances including work or worklike settings, and obsessional rituals which interfere with routine activities. He was deemed competent to manage his financial affairs. He underwent another VA examination for his PTSD in August 2012, which again determined that his diagnosed PTSD resulted in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgement, thinking and/or mood. He reported issues with his sleep sometimes requiring him to sleep in separate bedrooms from his wife due to his intense dreams previously resulting in his striking her in his sleep. He reported recently installing a bed rail to help him from falling out of bed. His occupational and educational history was significant for his having retired at age 58 and not working since 2008 due to anxiety and he continued to struggle in crowded areas. He enjoyed fishing but only when he was alone. His relevant mental health history revealed no changes since the time of the last exam. He continued to take prescribed Xanax and Zoloft as needed and increased his Xanax use when he leaves the house, including for this examination. On examination he was found to meet the diagnostic criteria for PTSD. His symptoms were as follows: Depressed mood, anxiety, panic attacks that occur weekly or less often, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, disturbance of motivation and mood, difficulty with establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, inability to establish and maintain effective relationships. Other symptoms included fear of leaving the house and increased suspiciousness since the time of his last exam. He continued to be competent to handle finances. The report of a November 2019 examination continued to diagnose chronic PTSD, which again was found to result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. He had last been employed in 2008. His symptoms were as follows: Depressed mood, anxiety, panic attacks that occur weekly or less often, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, 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 worklike setting and inability to establish and maintain effective relationships. Mental status examination was unremarkable, except that his mood was mildly depressed, and his insight and judgment were limited. When asked how military service has impacted mental health/symptoms, he reported that he has frequent nightmares, sometimes several times per night and he would wake up fighting/cussing, fearful, sweating. His wife reported that he has been to the emergency department twice for falling out of bed due to a nightmare. He also reported anxiety, and he can't be around crowds. He had some intrusive thoughts. His anxiety/panic were triggered by noises/sights from Fort Campbell. He had anxiety of going places, being around people. He was hypervigilant, and always checking, and suspicious. His wife accompanied him almost everywhere. Some confusion was noted, as was difficulty with short term memory. He would go to the wrong place, and his wife went with him to assist. He had some irritability, anger, and road rage. Despite treatment, the Veteran continues to experience significant ongoing symptoms. His service-connected disabilities significantly impact the ability to function in an occupational environment. Functional limitations were noted in concentration/persistence/pace and ability to adapt to stress/change. These impairments would significantly impact occupational and employment activities. However, he was found to be competent to manage his finances. Treatment records from the pendency of this claim beginning on January 24, 2012, and continuing prior to March 8, 2022. These records disclose that the Veteran received consistent long-term treatment for his PTSD including the VA/Vet Center including individual and group therapy. A January 2012 VA intake assessment note described his recurrent thoughts about combat experiences, continued nightmares, anxiety in populated areas, and around other people. He was constantly aware of surroundings, anxiety to noise or people and felt unsafe outside his home. He had significant guilt from combat experiences. However, he had no suicidal thoughts or history. He used alcohol after deployment but none currently. Mental status examination revealed he had a neat appearance, was friendly and cooperative, his speech was appropriate, he was fully oriented, and his memory was normal. He had appropriate affect and association was within normal limits. He had no evidence of a thought disorder, specifically with no delusions, delusional thinking, hallucinations or grossly disorganized or catatonic behavior. Other notes from January 2012 included an occupational history of having worked as a supervisor for a security company and worked for security at Fort Campbell. He retired at Fort Campbell in 1985. He lived with spouse and managed most household chores. On mental status examination, he appeared oriented to person, place, and time. He reports moderate difficulty with anger/irritability, desires to be alone, difficulty concentrating, excessive sweating, rapid breathing, rapid heart rate and feelings of depression. He also reported severe difficulty with loss of interest, feelings of detachment from others, short term memory problems, inability to stop thinking about upsetting events, guilt, flashbacks, troubles with reminders of bad events. The VA social work records repeatedly described his PTSD symptoms to include paranoid, isolation, anger/irritability, emotional detachment/numbness, loss of interest in work or play activities, poor concentration, short term/long term memory loss, hyperarousal, unable to stop thinking about upsetting events, nightmares, flashbacks, panic attacks, always on guard, trouble getting to sleep, trouble staying sleep, anxiety, panic attacks, grief, feeling of helplessness, intrusive thoughts, crying spells and feelings of sadness. This was shown in records from August 2012, January 2013, August 2013, August 2014, October 2015, April 2016, and October 2016, among others. The VA records throughout the pendency of the appeal prior to March 8, 2022, continued to document persistent and severe sleep disruptions from nightmares/night terrors, anxiety, and anger/irritability. However, the records also are repeatedly negative for suicidal/homicidal ideation or evidence of a psychosis/thought disorder. These include records from within a year of his January 2012 claim, with Social Work notes from July 2011 and September 2011 that described issues of difficulty being around people and that he was particularly bothered by fireworks on the Fourth of July. He also endorsed panic attacks and sleep problems with him hitting and kicking his wife in his sleep, with the July 2011 record indicating that his nightmares improved with medication, and he was calmer. These records also indicated that the PTSD symptoms were not constant, as he described the PTSD as sometimes bothering him, and sometimes it does not. The social work notes from February 2012, April 2012 and June 2012 documented severe sleep disruptions from his PTSD, resulting in his screaming and striking out in his sleep, and medication was no longer helping. He also endorsed a few panic attacks in April 2012 as well as an angry consultation with customer service over a computer issue. His wife also described issues with his temper and his inability to be out in public for long periods of time in the April 2012 note. A June 2012 note described the Veteran as having actually injured himself during a night terror when he fell out of and had to go to the hospital. He put a pad around his bed to prevent further injury. He also reported getting angrier including with his wife and was more hypersensitive and withdrawn from his kids. He also indicated he almost struck a VA nurse when she kept trying to twist his frozen ankle but managed to refrain from doing so. However mental status examination revealed him to be fully oriented times 4, dressed appropriately, with no disturbances in speech or psychomotor activities or gait. His mood was depressed/anxious/frustrated, and his judgement was fair, with good insight. His thought process is linear, logical, and goal directed, thought content is without SI/HI or perceptual disturbances and no overt psychosis noted. Records from September and November 2012 continued to document issues with flashbacks, nightmares/night terrors, reactions to loud noises including fireworks, and intrusive thoughts, with mixed results from his medications. He thought the medications helped in September 2012 but by November 2012 he complained that the medications were not helping his nightmares and he reported a panic attack in the waiting room. In January 2013, March 2013, and April 2013, he indicated his medication regimen was helping his mood and anxiety control, although he continued with nightmares and insomnia, and he continued to deny issues with suicidal ideation, homicidal ideation, and psychosis. He had outside stressors from medical issues with himself and his wife. In May 2013 the Veteran described concerns about time limited therapy, indicating it was helping his symptoms and he feared his anger and anxiety would get worse if it stopped. He said that before beginning treatment he became angry enough to hurt someone. He described flashbacks triggered by living close to Fort Campbell where he could hear bombs and artillery. He continued to have nightmares and his wife slept in a different room. Records from August 2013 discussed issues with bad dreams, anger, issues with "aggressive people" and startle responses to sudden noises. However, in September 2013 he described doing well on his medication regiment which was keeping his mood, anxiety, and nightmares in better control. A December 2013 social work note was significant for the Veteran reporting a flashback during his group meeting and he had to leave. He complained that his PTSD was severe and expressed frustration about his disability claim. Mental status examination was the same as shown in June 2012. VA treatment records from February 2014 were significant for increased nightmares and severe depression with a history of his brother's recent death the previous month. He had to cancel his trip to the funeral due to a snowstorm. Mental status examination was unchanged from that shown in September 2013. A June 2014 record noted anger surrounding his VA claim and his nightmares were back, and he injured his elbows during night terrors. Likewise in August 2014 he complained of having nightmares all the time and felt unable to do things he used to do or go places he used to go to. He had to double check everything and described his house as "like Fort Knox." Mental status examinations in June 2014 and August 2014 were essentially the same as the prior ones with no evidence of suicidal/homicidal ideation or overt psychosis. In October 2014 he described that he was not doing well since his medication dosage was lowered. He was concerned about being able to manage stress without Xanax and was explained about alternative choices to this medication which was being tapered. He became upset and walked out of the session. A December 2014 social work note described how the Veteran does not travel the interstate because of his anxiety and that his anxiety was worse when under stress. He reported nightmares and that his wife had rails and padding on the bed to protect from his outbursts while sleeping. He was trying to take care of his wife but they both had conditions. He also gave a history of having to see an outside psychiatrist while working in the prison because he threw a chair at the warden. He indicated he could deal with inmates, but the staff made him angry. A December 2014 PTSD consult note also described anger issues resulting in clashes with a prior mental health provider and that he had a history of injuring himself jumping out of bed during nightmares and he had a fully padded bed. VA records from 2015 show that in March he indicated going a while without nightmares. However, they came back and he continued to have to sleep in a padded bed due to night terrors. He had a dog, which kept him calm. He still endorsed difficulty being around a lot of people and was triggered by fireworks. An April 2015 individual note described an improvement with nightmares which were less frequent, and he was getting around 7 hours of sleep. He continued with ongoing anxiety especially in crowds and his mood had improved although he was a little depressed. His wife's illness was his primary stressor. He used coping strategies such as quiet time and watching TV. Mental status examination continued to be unremarkable for significant manifestations, other than flat affect. He was diagnosed with PTSD, moderate with associated depression. In July 2015 and in September 2015 he was having worsening anxiety and depression that may be related to his wife's declining health, but he denied suicidal ideation. By November 2015 he had an improvement in his mood with his anxiety level decreasing although he still had occasional nightmares. Mental status examination continued to be unremarkable for any major thought disorder. The impression was history of PTSD and MDD and his depression and anxiety related to his wife's health had improved. A December 2015 record noted continued issues with night terrors including a history of having broken three lamps and was rushed to the ER due to hitting his head on the nightstand. His PTSD was described as severe, however mental status examination continued to be unremarkable for any major disturbances in thought/overt psychosis. VA records from 2016 reveal that in March 2016 he continued to be active in PTSD group and individual psychotherapy. He reported doing okay with a minor increase in nightmares that fluctuate. He described having a few good weeks followed by a bunch of bad nights. Mental status examination continued to be generally unremarkable. In April 2016 he had increased depression due to caregiver stress as his wife's health was worsening. He reported doing all the cooking, shopping, and driving her to appointments, which was hard. He felt that meditation was helping his nightmares but was not getting restorative sleep. His mental status examination continued to be unremarkable for major thought disturbances. In May 2016 he reported doing "okay" with a period where he had no nightmares for a week, but they had returned. He continued to have an unremarkable mental status examination. His depression and anxiety related to his wife's health had improved but he was chronically dysthymic. He was assessed with PTSD, no change and MDD slightly worse. A June 2016 record noted continued night terrors with padding still around his bed and the history of violent thrashing and punching resulting in broken lamps was noted. He also had ongoing panic attacks in stores and flashbacks triggered by nearby aircraft from Fort Campbell. He was frustrated with the severity of his symptoms. In August 2016 an individual note described the Veteran as having night terrors every night and a history of sleeping apart from his wife for 5 years in a padded bed. Home support for his wife was discussed but he was distrustful of strangers and his wife didn't want any more caregivers. There were no nearby relatives to help out. Mental status examination was significant for his mood not being good but with no other significant findings. A September 2016 individual session note indicated that his sleep medication was helping out his night terrors, decreasing their frequency although his symptoms were still bad. His mental status examination was unremarkable except for a frustrated/depressed mood. In October 2016 a social work note addressing severe PTSD reported ongoing depression, and severe PTSD symptoms with night terrors and he also had caregiver stress. He reported that he had night terrors that again caused him to fall out of bed. In December 2016 he had recently got out of the hospital for an infection and reported a high level of stress with a night terror the last night. Records from 2017 include a February 2017 individual session describing ongoing concerns about his wife's health. At that time, he had no improvement with his night terrors. His mental status continued to be unremarkable except for frustrated/depressed mood. In April 2017 he described being tired during the day with continued stress and ongoing severe night terrors requiring padding on his bed. He indicated he could not remember his nightmares. In May 2017 he was seen for having a lot of anxiety and indicated Memorial Day brought back a lot of traumatic memories. He continued to endorse violent night terrors. His sleep problems were described as having created severe problems with his mood, concentration, and focus. His PTSD symptoms have been chronic for years. In July, August, and September of 2017 his anxiety was getting worse and indicated that he can be sitting down doing nothing and start shaking. He reported panic attacks and difficulty with his neighbor's fireworks over the Fourth of July. He also expressed that night terrors were interfering with sleep and causing problems with his mood. He indicated that anxiety was interfering with his ability to drive to appointments. The records also focused on his ongoing concerns with his wife's health, and it was reported that nightmares from combat were worse with his wife being ill. In November and December 2017, he was seen for grief and severe PTSD symptoms as his wife had passed, although he indicated he was doing okay. He continued to struggle with night terrors. His daughter called daily to check on him and he had good family support. His night terrors were getting worse and sleep problems continued to create severe problems with mood, concentration, focus and PTSD symptoms. He reported waking with actual panic attacks, feeling like his heart is coming out of his chest. Records from February 2018 focused on his grief following his wife's passing and his coping with being alone. He denied a problem with addiction. In March 2018 he reported a decrease in the frequency of anxiety episodes, and he felt that medications were helping. He indicated he was feeling pretty good but still having bad dreams. Records from April 2018 discussed him trying to stay busy, and he became frustrated with some appointment issues at the VA, and he got upset and left. In May 2018 he discussed the major changes since his wife's passing with a family member moving in to help out with cooking and cleaning. He still had severe anxiety and cannot be around a crowd, describing how he had to sit in the last row at the movies. In September 2018 he described having nightmares that happen more when under undue stress, with PTSD symptoms remaining significant. He had just had his last radiation treatment for cancer. In November 2018 he reported having fallen out of bed twice, having hit the corner of the dresser and he bought an air mattress to put on the floor. He was unsure what triggered his nightmares although he was concerned about the health of an extended family member. He was assessed with chronic severe PTSD and his mental status examination was not significant for any signs of a major thought disorder or cognitive impairment. Records from 2019 reveal that on January 2, 2019, he discussed his multiple Vietnam related stressors. He indicated he could not tolerate loud noises and reported nightly violent night terrors; he now used an air bed on the floor. The Veteran reported that he had depression with feeling of hopelessness and was afraid to go to bed due to his sleep being constantly interrupted due to night terrors. His anxiety was severe, and he was concerned that his mental health medication was not helping him like it previously did. He had near continuous panic attacks affecting his ability to function independently. He had impaired impulse control, and unprovoked irritability. The Veteran had a history of irritability and anger at times when interacting with people generally, low threshold for stressful circumstances. Short-term memory is not good. He was not clinically appropriate for discharge. In the best interest of his mental health, he was better served by receiving long-term psychotherapy, trauma focused therapy, incorporating evidence based as clinically appropriate and supportive therapy underlines all. In a February 2019 social work session, the Veteran informed that nightmares are currently happening five times in one night. He was worn out from the nightmares from fighting in his sleep. He was deemed not clinically appropriate for discharge from his psychotherapy program. His history dating back to 2012 was discussed in detail. In May 2019 he was seen for his PTSD with ongoing symptoms including Veteran reports ongoing symptoms including intrusive thoughts, nightmares that lead to sleep disruption, anxiety, low mood and irritability at times, and isolative/avoidant behaviors as being primary reasons for ongoing therapy. He reported recent/current medical stressors have worked to exacerbate his experience of mental health symptoms. Mental status examination showed him to be fully oriented, well groomed, dressed casually, appropriate for the weather, with appropriate eye contact. His mood was anxious/guarded but pleasant, and his affect was congruent. The same complaints and mental status findings were reported in June 2019, although the Veteran reported a new injury from jumping out of bed during his nightmare and receiving a concussion. An August 2019 medication management note noted that he was widowed 3 years ago and was married again in January 2019. He reported a history of three trips to the ER for injuries from falling out of bed due to nightmares. He reported that meeting and marriage to his current wife over a year ago and she "saved my life" because he was so isolated and depressed after his first wife died. He continued to deny homicidal and suicidal ideations and audio-visual hallucinations. Also in August 2019, psychiatric therapy notes for PTSD symptoms, described the same as in May 2019. In this session the Veteran reported ongoing symptoms of PTSD, the most disruptive of which being nightmares which lead him to become physically aggressive at times, acting out in his sleep. He reported no change in other persistent symptoms as described during his initial session with this provider. Mental status was the same as in May 2019. A September 2019 VA treatment record noted that despite his difficulty sleeping he shared how excited he was to be going on a trip with his family to the mountains. He expressed some concerns about possibility of dangerous wildlife though. He also expressed thankfulness for family and life despite the challenges he was facing. VA treatment records from 2020 reveal that in March 2020, he reported that he was having fewer nightmares than before. He denied past hospitalizations for behavioral health (BH) and self-harm behaviors. He again described his marriage to his current wife and having "saved his life" because he was isolated and depressed after his first wife passed. He described that he and his family were healthy but getting bored at home. He continued to report fewer nightmares in July 2020, with his mental status examination unremarkable for any evidence of a thought disorder or other major mental impairment, including no homicidal or suicidal ideations. In November 2020 he reported more frequent nightmares the past 2 months, with his wife waking him up to tell him he is dreaming more often. He continued to report satisfaction with his wife and family situation although they were getting bored being at home. Mental status examination continued to be unremarkable. He continued treatment for PTSD in 2021. In January 2021 and March 2021, he complained of worsening depression, but he continued to deny past BH hospitalizations or self-harm behaviors. He continued to express that things were well with his wife and family situation. A February 2021 notes also noted complaints of lots of anxiety and nightmares almost nightly but did not recall the contents of his dreams. He also said he gets angry and has to make sure everything is locked up due to the current environment. A May 2021 record revealed the Veteran expressed increased shortness of temper with Covid precautions and was frustrated with the VA rating process. He continued to express satisfaction with his marital and family situation. In July 2021 he again reported issues with anxiety, nightmares, and anger issues. He also described a situation when he was working at a correctional facility and how he reacted to an inmate attacking him by beating the inmate with the mop handle that had been used to attack him. He also reported once calling in the guard tower to shoot another inmate who had shot at another inmate. The treatment records continued to be negative for any issues with homicidal or suicidal ideation or evidence of psychosis. Psychiatry notes from September 2021, October 2021 and January 2022 disclosed complaints that he was tired and continued to have issues with nightmares. His mental status continued to be negative for any evidence of a thought disorder, including no homicidal or suicidal ideations. The January 2022 records indicated that he was about to start CPAP and thought that this would help with his nightmares. In February 2022 the receipt of his CPAP equipment was discussed. The Veteran was granted a 100 percent rating effective March 8, 2022, the date he filed a VA-21-526 EZ alleging an increased rating for PTSD and TDIU despite the fact that these were already pending on appeal. The evidence forming the basis for the grant was a June 2022 VA examination which determined the Veteran has total social and occupational impairment due to PTSD symptoms. He was also found to not be competent to manage finances. Severe symptoms of PTSD prevent him from working. Having reviewed the evidence for the appeal period prior to March 8, 2022, the Board finds that a higher rating of 100 percent is not warranted, as the competent evidence does not reflect total social and occupational impairment. Although his symptoms are severe, particularly those concerning his severe sleep impairment with night terrors resulting in injuries to himself while sleeping, and his issues with anger and occasional outbursts, these symptoms, and their resultant impact, are contemplated by the 70 percent rating currently in effect. The Board does concede that the evidence shows significant impacts on his ability to obtain and maintain substantially gainful employment which will be addressed further in the decision on his TDIU claim. However, the Veteran's symptoms are not shown to result in a total social and occupational impairment. He is shown to have had meaningful relationships with his first wife and family and participated actively as her caregiver during her lengthy and ultimately terminal illness. Following her passing, he remarried in 2019 and has repeatedly described the relationship as a positive influence on his life. Despite his severe symptoms he was able to participate in family activities including trips as reported in September 2019. Although his symptoms such as anxiety and panic attacks negatively impacted his ability to be out in public, he was able to do things such as shop with assistance and reassurances from his current wife or attend movies with certain seating accommodations away from the crowd. Additionally, there is no showing of persistent delusions or hallucinations throughout the pendency of this appeal prior to March 8, 2022. At no point have the records shown him to have issues with suicidal or homicidal ideations, although he has had occasional outbursts of violent acts during periods of extreme stress. His objective mental status examinations have repeatedly been unremarkable for delusional thought, hallucinations or suicidal or self-destructive behavior. His most severe symptoms resulting in harm to himself are shown to be his persistent severe sleep disruptions due to night terrors that have resulted in injuries and have required accommodations to his bed to prevent such injuries. Such symptoms impacting his sleep, as well as his anxiety and panic attacks are noted to fluctuate in frequency and severity, worsening in periods of high stress, and also by changes in medication regimen. The Board acknowledges his social isolation, but finds that such social function, though limited, does not reflect total social impairment. Accordingly, the Board finds that when viewed against other evidence of record, to include the VA treatment records and Vet Center records, that the Veteran's overall disability picture is more nearly approximated by the 70 percent evaluation, and not a 100 percent rating. Therefore, after looking at the totality of the Veteran's PTSD disability picture, the Board finds that the preponderance of the evidence does not warrant a rating in excess of 70 percent, but no higher, for the entire period on appeal prior to March 8, 2022. 2. TDIU The Veteran contends that his PTSD symptoms render him unemployable. At his January 2019 hearing he testified that he last worked in 2008 in corrections and had to leave this job due to anxiety and anger issues. He indicated this was his primary field of employment. He expressed that he is no longer able to work due to PTSD and indicated that he would not be able to get along with coworkers. He testified that he worked 16 years at the state penitentiary and quit due to his symptoms. He denied working or seeking employment since 2008. Transcript 1/19 hearing pg. 11-16. A total disability rating may be granted where the schedular rating is less than 100 percent and the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Generally, to be eligible for a TDIU, a percentage threshold must be met. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In determining unemployability for VA purposes, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). The sole fact that a veteran is unemployed or has difficulty securing employment is not enough, as a high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). Entitlement to TDIU is based on an individual's particular circumstances. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). In making a determination, the Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. For the appeal period from January 24, 2012, prior to March 8, 2022, the Veteran has been in receipt of a combined 90 percent evaluation. Therefore, his evaluation for compensation due to his service-connected disability meets the percentage rating standards for TDIU under 38 C.F.R. § 4.16 (a) from January 24, 2012, prior to March 8, 2022. His compensable (greater than 0 percent) service connected disabilities for the appeal period from January 24, 2012 prior to March 8, 2022 are rated as follows: PTSD rated 70 percent, fracture of the right ankle with traumatic arthritis rated 40 percent, diabetes mellitus rated 20 percent from January 24, 2012, 10 percent from June 1, 2014 and 20 percent from July 8, 2015, residuals of prostate cancer 20 percent from March 13, 2019, tinnitus rated 10 percent, glaucoma 10 percent. The combined rating for the period from January 24, 2012, prior to March 8, 2022, is 90 percent. See 38 C.F.R. § 4.25. Other compensable disabilities were added on March 8, 2022, which are outside this appeal period as a 100 percent rating is in effect as of that date. Additionally, on March 8, 2022, he was awarded entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114 (s) based on the 100 percent schedular rating for PTSD with additional disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. This 100 percent rating for PTSD and the SMC award rendered moot the claim for TDIU as of March 8, 2022. See 38 C.F.R. § 3.350. See also Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Thus, the appeal period remaining before the Board is the period from January 24, 2012, prior to March 8, 2022. Initially, the Board finds that the evidence supports a finding that the Veteran has submitted a substantially complete VA Form 21-8940 as required to establish entitlement to Individual Unemployability. In his June 2012 application, he reported working as a supervisor for the Department of Corrections from 1987 to 2003 and worked 40 hours/week and earned $1600 a month. He then worked in security from 2003 to 2004 and worked a 40-hour week earning $1800 a month. He reported his current income was from Army retirement and VA benefits and was $3830 a month. He reported having a high school education with no additional education. In this application he claimed entitlement to TDIU due to PTSD, Type 2 diabetes with cataracts, glaucoma, hearing, ankle, and tinnitus. A review of the evidence discloses that from the pendency of this appeal and continuing prior to March 8, 2022, the Veteran's PTSD symptoms result in unemployability, based on the severity of his symptoms and in light of his level of education, special training, and previous work experience. The VA examinations in March 2012, August 2012 and November 2019 all determined that his PTSD resulted in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. A November 2015 VA examination addressed the Veteran's claim for TDIU, noting his contentions that this was due to PTSD. The examiner reviewed the veteran's VBMS chart and VA medical records. His most recent C&P exam in 2012 noted that he retired at age 58 due to his anxiety. The examiner opined that the Veteran's current symptoms remain significant enough to affect his occupational functioning. He was noted to be chronically anxious and had a poor tolerance for stress. The examiner opined that he would likely have trouble tolerating jobs of even a moderate stress level. His symptoms were also associated with reclusiveness, and he would have trouble being in a bustling or noisy workplace. A review of notes indicated that he is vulnerable to anxiety while driving due to his symptoms. The examiner concluded that he would function best in a low-stress job that allowed him to work alone or nearly alone and at his own pace in a quiet environment. Regarding his most significant employment experience, of working in the department of corrections, his PTSD symptoms which included anxiety and angry outbursts were shown to have negatively impacted his work to the point where he had a violent outburst resulting in his throwing a chair at a supervisor as reported in the December 2014 social work note. This note also described the Veteran reporting anger issues towards supervisory staff. He also described an overly reactionary response to an attack by an inmate where he ended up beating the inmate with a broom handle per a July 2021 note. By his own admission his PTSD symptoms forced him to quit his job in corrections. The November 2015 TDIU examination indicated that he would essentially require a job in a low stress environment where he is alone. His symptoms are well documented in the records discussing his PTSD, including anxiety, nightmares/night terrors and anger issues and would preclude his prior career in corrections and security, which would potentially involve episodes of a stressful environment. In this case, the record reflects that the Veteran's service-connected PTSD greatly hinders ability to interact with others. His records document that he has had issues with interpersonal conflict with others and also had issues with isolation, motivation and concentration impacting his employability. There is no indication in the record that the Veteran has any other experience in a position other than corrections or security. As a result, the difficulties posed by his service-connected disabilities prevent him from being able to secure or follow a substantially gainful occupation as of the pendency of this claim from January 24, 2012, continuing prior to March 8, 2022. Therefore, the Board finds that when resolving all reasonable doubt in favor of the Veteran, the evidence shows that his service-connected disabilities render him unable to secure or follow a substantially gainful occupation from approximately January 24, 2012, onward prior to March 8, 2022. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Eckart, C. 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.