Citation Nr: 24012437 Decision Date: 03/18/24 Archive Date: 03/18/24 DOCKET NO. 17-55 766 DATE: March 18, 2024 ORDER Entitlement to an initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) for the appeal period prior to December 4, 2018 is granted. Entitlement to a total rating based on individual unemployability due to service connected PTSD (TDIU) is granted. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's PTSD has manifested as occupational and social impairment with deficiencies in most areas without total occupational and social impairment. 2. Throughout the period on appeal, the Veteran's service connected PTSD rendered him unable to obtain and maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating of 70 percent, but no higher, for PTSD for the appeal period prior to December 4, 2018 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to a TDIU due to PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1966 to July 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before a Veterans Law Judge at a November 2019 hearing; a hearing transcript has been associated with the claims file. The Veterans Law Judge who conducted the November 2019 Board hearing has retired and is no longer employed by the Board. In a February 2024 letter, the Board informed the Veteran and his representative that the Veterans Law Judge who conducted the hearing in November 2019 was no longer employed by the Board and provided the Veteran the opportunity to testify at another Board hearing. The letter further informed the Veteran that, if he did not respond within 30 days, the Board would assume that he did not want another hearing and proceed accordingly. To date, he has not responded to the February 2024 letter. Therefore, the Board will assume that the Veteran does not wish to appear at another hearing and will proceed with adjudication. In October 2021, the Board issued a decision which denied entitlement to an initial rating in excess of 50 percent for PTSD for the appeal period prior to December 4, 2018, granted entitlement to an initial rating of 70 percent for PTSD for the appeal period beginning on December 4, 2018, and denied entitlement to a TDIU prior to and since December 4, 2018. The Veteran subsequently appealed that decision to the United States Court of Appeals for Veterans Claims (Court). Insofar as the Board granted entitlement to an initial rating of 70 percent for PTSD effective December 4, 2018, the Court did not disturb that favorable finding. The Court also noted that the Veteran did not wish to pursue entitlement to an initial rating in excess of 70 percent for PTSD from December 4, 2018 and dismissed the appeal as to that issue. In a September 2022 Order, the Court granted a Joint Motion for Partial Remand of the parties vacating those parts of the October 2021 Board decision that denied entitlement to an initial rating in excess of 50 percent for PTSD for the appeal period prior to December 4, 2018, and entitlement to a TDIU prior to and since December 4, 2018, and remanded the case to the Board for action consistent with the Joint Motion for Partial Remand. The Board notes that the parties in the Joint Motion for Partial Remand requested that the Board consider and address whether the record reasonably raised the issue of entitlement to service connection for gastroesophageal reflux disorder as secondary to service connected PTSD. In July 2023 correspondence and prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran, through his attorney, that a withdrawal of the issue of entitlement to service connection for gastroesophageal reflux disorder was requested, and that the Veteran's gastrointestinal symptoms be attributed to his PTSD and considered when evaluating the proper rating for his PTSD. As such, the Board will not address such claim herein. The Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU due to a service-connected disability is part and parcel of an increased rating claim for that disability when raised by the record. In the present case, the Veteran contends that his service connected PTSD renders him unable to obtain and maintain substantially gainful employment. See January 2020 VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability (TDIU Claim Form). Accordingly, the issue of entitlement to a TDIU is before the Board. See Roberson v. Principi, 251 F.3d 1378, 1384 (2001) ("[O]nce a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally submits evidence of unemployability, the VA must consider... TDIU."). Finally, the Board notes that new evidence was submitted after issuance of the April 2020 Supplemental Statement of the Case (SSOC); however, the Veteran, through his representative, waived consideration of the evidence by the agency of original jurisdiction (AOJ). See August 2021 Appellate Brief Presentation; see also July 2023 Correspondence. Therefore, it is not necessary to remand the claim to the AOJ for consideration of the evidence in the first instance. 38 C.F.R. § 20.1305(c). 1. Entitlement to an initial rating of 70 percent, but no higher, for PTSD for the appeal period prior to December 4, 2018 is granted. The Veteran, through his representative, asserts that at minimum a 70 percent rating is warranted for his service connected PTSD for the appeal period prior to December 4, 2018. See July 2023 Correspondence. Specifically, the Veteran asserts that he exhibits occupational and social impairment with deficiencies in most areas based on symptoms such as suicidal ideation and near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. Id. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA's determination of the present level of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Hart v. Mansfield, supra. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, supra. The veteran's entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, supra; Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, supra. The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim. When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). During the period on appeal, the Veteran's PTSD is rated as 50 percent disabling for the appeal period prior to December 4, 2018 under the General Rating Formula for Psychiatric Disabilities (General Formula). 38 C.F.R. § 4.130. 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, 442-43 (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 Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, a 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material; forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of 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 United States 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 September 2022. As such, the DSM-5 applies, and the GAF scores will not be considered. A review of the record reveals that the Veteran sought mental health treatment from VA treatment providers, as well as treatment for his other health needs. To the extent that the Veteran's treatment records contain information relevant to the severity of his mental health, to include mental health screenings, the Board will summarize this evidence. During an August 2015 psychiatric evaluation, the VA provider opined that the Veteran was able to independently handle the activities of daily living, to include bathing, dressing, toileting, transferring, continence, feeding, telephoning, traveling, shopping, preparing meals, housework, and medication. During a January 2016 VA examination, the Veteran reported that he was less active and more sedentary than in the past. His normal routine includes waking up early to take his dog for a walk and spending most of the day around the house. He indicated that he spends a lot of time by himself and has for many years. He also reported then currently being in his third marriage, but he added that he had been married to this third wife for 26 years and that it is a good marriage. He also indicated he has four children from his first marriage and that he has a good relationship with his children. The examiner explained the Veteran's PTSD symptoms included depressed mood, anxiety, and chronic sleep impairment. The examiner stated the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Along with his depressed mood, he endorsed symptoms including being withdrawn, isolation, loss of interest, low energy, and guilt. His anxiety symptoms included avoidance of crowds, impeded his ability to drive, hypervigilant, difficulty concentrating or lost in thought, irritability over little things, muscle tension, sleep disturbance, excessive worrying, and panic attacks. He appeared clean and neatly groomed. The examiner observed the Veteran's thought processes are linear, logical, and goal directed. He also denied suicidal and homicidal ideation. An April 2016 VA psychiatry note shows the Veteran was experiencing anxiousness and depressive symptoms that included panic attacks, generalized anxiety, and depressed mood. He reported that he had stopped taking his medication but was sleeping "great" at night, no longer taking the trazodone as he is able to both fall asleep on his own and stay asleep on his own. He also indicated that he had worked security for a school system and retired in 2013. As well, he stated that he enjoys kayaking, walking on the beach, painting, going to museums, and raising honeybees. During the objective mental status portion of the examination, the examiner observed the Veteran was appropriately dressed, groomed, and had good hygiene. His speech was spontaneous, non-pressured, and coherent. His thought process was logical and organized. He did not have any hallucinations, delusions, or paranoia. His cognition was intact with a good recall of recent events. He also again denied suicidal or homicidal ideation. In a November 2016 VA treatment note, the examiner indicated the Veteran was casually dressed and that his hygiene was adequate. His judgement and insight were fair. His thought processes were noted as goal directed, logical, and coherent. He also denied suicidal ideation. In October 2017, VA received a statement from the Veteran. For family relations, he described constant panic attacks that interfered with daily trips to the store and any other travel. Furthermore, the Veteran stated that he could not deal with any stressful situations. The Veteran indicated an injury during service caused traveling problems. For day-to-day activities, according to the Veteran, medication for his anxiety had caused many side effects which had been so severe that he wanted to kill himself, resulting in a trip to the emergency room. As to occupational and social impairment, the Veteran stated that he had no close relationships with his children or other members of the family. The Veteran stated that he was retired but could never get involved in work or family activities. According to the Veteran, obsessive rituals every day limited his ability to function normally and that he had to be in control of every situation or it was avoided completely. The Veteran stated that he had constant suicidal thoughts and spoke illogically about ordinary situations. According to the Veteran, constant panic attacks limited his relationships, travel and his ability to function independently. In addition, the Veteran stated that his irritability had caused his marriage to be in jeopardy. The Veteran added that he had trouble adapting to stressful situations, did not care about his personal appearance, and always felt hopeless. In addition, the Veteran noted experiencing memory loss since returning from service that had progressively worsened over the years. During a November 2019 Board hearing, the Veteran testified that he minimized some of his responses to questions by VA providers because he did not want them to think he was crazy. In a June 2023 independent medical evaluation, Dr. J.T. opined that by 2015, the Veteran was living a reclusive lifestyle, isolated by severe anxiety, panic, depression, and associated physical symptoms. A review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities. However, there is no indication from the record that his PTSD symptoms are manifestly different than those reported at above-mentioned examinations and treatment notes. Based on the evidence of record, the Board finds that an initial rating of 70 percent, but no higher, throughout the period on appeal prior to December 4, 2018 for the Veteran's PTSD is warranted. The Veteran's overall disability picture more closely approximates the criteria for a 70 percent rating, which contemplates occupational and social impairment with deficiencies in most areas. In this regard, at the January 2016 VA examination, the Veteran reported that he was socially isolated outside of his wife and children. In an October 2017 statement, the Veteran indicated that he had not attempted to work during this period and that he experienced constant panic attacks that limited his relationships, travel and his ability to function independently; such establishes impairment to work. The Veteran noted difficulty with memory and constant suicidal thoughts; as such, impairment to thinking is demonstrated. The Veteran also noted that he did not care about his personal appearance. Impairment to mood was demonstrated as the Veteran reported anxiety and depression. In a June 2023 medical opinion, the provider noted that the Veteran was living a reclusive lifestyle, isolated by severe anxiety, panic, depression, and associated physical symptoms. Schooling was not attempted during the appeal period. As such, occupational and social impairment with deficiencies in most areas was demonstrated. See 38 C.F.R. § 4.130, Diagnostic Code 9411. However, the Board finds that at no point pertinent to the higher rating claim has the Veteran displayed a total social and occupational impairment as indicated by symptoms such as spatial disorientation, gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, disorientation to time or place and memory loss for names of close relatives, own occupation or own name. Notably, the January 2016 VA examiner did not find that the Veteran's symptomatology produced total occupational and social impairment. The Board notes that the Veteran expressed suicidal ideation, which may constitute a persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, supra. However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent rating. Although he reported constant suicidal ideations and asserts that he was admitted to the emergency room, the Board finds that this does not equate to a persistent danger of hurting self or others. Rather, during the period on appeal prior to December 4, 2018, the Veteran has no history of suicide attempts. The record shows that the Veteran experiences significant social impairment; however, the Veteran had maintained a good relationship with his wife and children during the period on appeal. In April 2016, the Veteran noted he lived with his wife, enjoyed kayaking, walking on the beach, painting, and going to museums. Such does not establish total social impairment. In addition, the August 2015 VA provider specifically found the Veteran's appearance to be within normal limits based upon objective examination which suggests that the Veteran was able to maintain personal hygiene. Therefore, a total level of impairment has not been demonstrated in the clinical evidence or alleged by the Veteran. For these reasons, a total rating for PTSD is not warranted. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In assessing the severity of the PTSD, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board notes the contentions of the Veteran that his PTSD is more severe than currently shown on examination; and the Board observes that the Veteran, while competent to report his observable symptoms, he is not competent to report that his mental health symptoms are of sufficient severity to warrant a higher rating under VA's tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). Despite the foregoing, the Board acknowledges the Veteran and his representative's reports of the Veteran's symptoms. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for higher ratings are not met. The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). This argument is therefore without merit. The Board has considered whether a staged rating under Hart v. Mansfield, supra is appropriate; however, the Board finds that his symptomatology has been otherwise stable throughout the period on appeal. Therefore, assigning a staged rating is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Accordingly, the Board finds that an initial rating of 70 percent, but no higher, for PTSD for the appeal period prior to December 4, 2018 is warranted. To that extent, the appeal is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra. 2. Entitlement to a TDIU due to service connected PTSD is granted. The Veteran contends that his service connected PTSD prevents him from securing or following any substantially gainful employment. See January 2020 TDIU Claim Form. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Rating boards should submit to the Director of Compensation Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, supra. Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering a veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering a veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering a veteran's master's degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. 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 obtain or keep 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. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). A claim for TDIU may be filed as a freestanding claim. In addition, TDIU may be an element of a claim for an increased disability rating when unemployability is raised by the record. See Rice v. Shinseki, supra. In the instant case, and as of the date of this decision, service connection is in effect for PTSD, rated as 70 percent disabling from October 22, 2015; and tinnitus, rated as 10 percent disabling from April 17, 2019. The Veteran's combined rating for compensation was 70 percent from October 22, 2015. Thus, the schedular criteria for a TDIU have been met throughout the period on appeal. The Board finds a claim of TDIU was raised by the record pursuant to the Veteran's claim for an increased rating for his service connected PTSD. See Rice, supra. The Veteran contends that his PTSD renders him unable to obtain and maintain substantially gainful employment. See January 2020 TDIU Claim Form. Therefore, the Board may proceed with adjudicating a TDIU claim. To the extent that the Veteran's psychiatric limitations and functional impact of his service-connected PTSD are discussed in the preceding section, the Board incorporates such herein. A review of the record demonstrates that the combined effects of the Veteran's service connected disabilities render him unable to secure and maintain substantially gainful employment throughout the period on appeal. The Veteran's occupational and employment history were discussed in the report of his January 2016 VA examination. He indicated that he is a high school graduate and denied attending college or receiving any post-secondary vocational training. The Veteran explained that he had worked in bakeries since the age of 14 and, afterwards, went on to own two bakeries with his second wife. After he divorced his second wife, he then worked for another bakery before starting his own bakery. He added that he owned and operated his bakery for approximately seven years then sold it. Once he sold his bakery, he went to work for the school system for eight years. He retired from the school system in 2012 and relocated to Florida. In the January 2020 TDIU Claim Form, the Veteran indicated that he last worked full-time in June 2013, and became too disabled to work in June 2013. He indicated that in addition to previously working as a baker, he last worked in security at 40 hours per week from 2005 to 2013. The Veteran reported that he earned no income in the past 12 months and that he left his last job because of his disability. In July 2023, VA received a copy of the Veteran's social security statement indicating no earnings were taxed for social security or Medicare. Turning to the evidence of record, the Veteran and his wife testified at a November 2019 Board hearing. The Veteran stated that he left his last position in security at a school because his PTSD symptoms caused him to anger easily and he was prone to outbursts with co-workers and when children misbehaved. The Veteran's wife asserted that the Veteran retired early because of his PTSD symptoms. In December 2019, the Veteran was afforded a VA examination for his service connected tinnitus. The examiner stated that the tinnitus impacted the Veteran's ordinary conditions of daily life, including the ability to work, as it interfered with sleeping, served as an annoyance, and was distracting. In a June 2023 independent medical evaluation by Dr. J.T., she stated that by 2015 the Veteran was living a reclusive lifestyle, isolated by severe anxiety, panic, depression, and associated physical symptoms. The provider stated that the Veteran was unemployable and incapable of functioning in a modern workplace or even basic social settings since at least 2013. She noted a December 2018 VA treatment record indicating that the Veteran put an unloaded gun to his head, and that the Veteran stated that more than half the days of the week he had thoughts that he would be better off dead, though he denied any suicidal thoughts or intent. The Veteran reported to the provider that he was a perfectionist after his military service in the Vietnam War and operated two successful bakeries but the stress caused by his perfectionism caused him to reduce his operating hours and eventually sell the bakeries. The Veteran reported to the provider that he worked in school security and physically dragged a student to the principal's office, snapped at a colleague, and was assigned to bus duty. The Veteran stated to the provider that he was about to lose it when parents began pulling in front of the buses and knew he needed to leave his job before he lost his temper around the parents. This resulted in him retiring and relocating to another state. The Veteran reported that he was always on edge since Vietnam. Dr. J.T. opined that the Veteran's perfectionism and hypervigilance were part of the reason that he could not sustain employees to keep his bakeries operating. Further, the provider said that the Veteran was unable to sustain his bakeries due to pervasive PTSD symptoms which caused him to be irritable, anxious, hypervigilant, and perfectionistic. According to the provider, the Veteran's severe symptoms would prevent him from interacting appropriately with customers or employees and impair his ability to manage the stress of running a business. The provider opined that this type of rigidity and inability to manage the logistics, interpersonal reactions and requirements of a complex work environment had prevented the Veteran from being employable in a modern workplace since at least 2013. In addition, the provider noted that the Veteran's limited ability to travel due to debilitating panic symptoms would prevent employment outside the home, and his limited education (high school graduate) would also greatly restrict his job opportunities. Therefore, Dr. J.T. concluded that the Veteran was socially and vocationally impaired based on the frequency, severity, and duration of his symptoms and he was totally disabled and unemployable since 2013, if not earlier. Based on the evidence of record, the Board finds that the combined effects of the Veteran's service-connected disabilities preclude him from maintaining substantially gainful employment that is consistent with his education and occupational experience. In this regard, the Veteran worded in the bakery and security industries in his post-service career. The Veteran's severe social anxiety, difficulty in establishing and maintaining effective work and social relationships, social isolation, depression, sleep disturbances, difficulty being in public or around others, difficulty adapting to stressful circumstances, including work or a worklike setting, and an inability to establish and maintain effective relationships, would impact his ability to work in these fields, or in any similar profession. These symptoms also impact his mental capacity to perform occupational activities due to concentration, and the ability to adapt to change and handle workplace stress. See Ray v. Wilkie, 31 Vet. App. 58 (2019). In this regard, as discussed in the preceding sections, the Veteran's psychiatric symptoms have been found to most closely approximate occupational and social impairment of, at worst, deficiencies in most areas. The medical evidence consistently demonstrates that the Veteran's psychiatric symptoms prevented him from interacting with others appropriately, to include anxiety, social isolation, suicidal ideation, panic attacks, amotivation, and sleep disturbances. The Veteran testified that he left his most recent employment due to symptoms of his PTSD. VA's duty to maximize benefits requires it to assess all of a claimant's service connected disabilities to determine whether any combination of the disabilities establishes eligibility for special monthly compensation under 38 U.S.C. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). In Bradley, the Court held that 38 U.S.C. § 1114(s) permits a TDIU rating based on a single disability to satisfy the statutory requirement of a "total" rating. When a veteran is awarded TDIU based on a single disability and receives schedular disability ratings for other conditions, special monthly compensation based on the statutory housebound criteria may be awarded so long as the same disability is not counted twice, i.e., as a basis for TDIU and as a separate disability rated 60 percent or more disabling. See 75 Fed. Reg. 11,229, 11,230; Summary of Precedent Opinions of the VA General Counsel (March 10, 2010) (withdrawing VAOPGCPREC 6-1999 in light of Bradley, 22 Vet. App. at 280). A veteran with a 100 percent schedular rating for a single service-connected disability could also obtain a TDIU on a single separate disability (though not on multiple service-connected disabilities), in order to meet the special monthly compensation requirements (100 percent rating plus 60 percent rating). A TDIU could meet the special monthly compensation requirements by either: a) increasing a single disability rating of less than 60 percent to at least 60 percent (in a case where a separate 100 percent rating is already established), or b) increasing a single disability that is less than 100 percent to a "total" (100 percent) rating, in a case where there is already established a combination of other ratings that meet the separate 60 percent rating requirement for special monthly compensation. See Buie at 249-50. The Veteran is being awarded a TDIU based on his service connected PTSD herein and he does not have service connected disabilities that are separately rated as 60 percent disabling. Therefore, special monthly compensation under 38 U.S.C. § 1114(s) for statutory housebound benefits is not warranted. Therefore, based on the foregoing, the Board finds that the Veteran's service-connected PTSD rendered him unable to secure and follow a substantially gainful occupation and entitlement to a TDIU is warranted for the appeal period. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Kuhn, 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.