Citation Nr: 24013418 Decision Date: 03/28/24 Archive Date: 03/28/24 DOCKET NO. 18-34 749 DATE: March 28, 2024 ORDER Prior to October 29, 2018, an initial rating of 70 percent for posttraumatic stress disorder (PTSD) with bipolar disorder and generalized anxiety disorder, is granted, subject to the laws and regulations governing the award of monetary benefits. An initial rating greater than 70 percent for PTSD with bipolar disorder and generalized anxiety disorder, is denied. A total disability rating for individual unemployability (TDIU), prior to October 29, 2018, is granted. FINDINGS OF FACT 1. Throughout the entire period on appeal, the Veteran's PTSD with bipolar disorder and generalized anxiety disorder, more closely approximates occupational and social impairment, with deficiencies in most areas. 2. Throughout the entire period on appeal, the persuasive weight of the evidence reflects that the severity, frequency, and duration of the Veteran's symptoms did not more closely approximate total occupational and social impairment. 3. Prior to October 29, 2018, the most probative evidence of record is in favor of finding that the Veteran's PTSD with bipolar disorder and generalized anxiety, precluded him from securing or following substantially gainful occupation. CONCLUSIONS OF LAW 1. Prior to October 29, 2018, the criteria for an increased rating of 70 percent for PTSD with bipolar disorder and generalized anxiety disorder, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, DC 9411. 2. Throughout the entire period on appeal, the criteria for an increased rating greater than 70 percent for PTSD with bipolar disorder and generalized anxiety disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, DC 9411. 3. The criteria for TDIU prior to October 29, 2018, have been met. 38 U.S.C. § 1155 5107, 5110; 38 C.F.R. §§ 3.102, 3.340, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran honorably served on active duty from June 1968 to June 1970, with service in the Republic of Vietnam. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) of the Veterans Benefits Administration (VBA), which is the Agency of Original Jurisdiction (AOJ). See Rating Decision dated October 2017. The Veteran initiated a timely appeal of this denial in VA's "legacy" appeals system. See VA Form 9 dated June 2018. The Board remanded this appeal in May 2020 and April 2023 for further development by the RO. During the pendency of the Veteran's appeal of the initial rating for PTSD the Veteran sought a TDIU based on a mental health condition. See VA Form 21-8940 dated November 2018. The AOJ granted the TDIU effective October 29, 2018, the same effective date of the Veteran's 70 percent rating for his service-connected psychiatric disorders. See Rating Decision dated October 2019. Therefore, the TDIU claim is part of the Veteran's initial rating claim for his service-connected PTSD with bipolar disorder and generalized anxiety disorder. Accordingly, the Board will consider whether a TDIU is warranted prior to October 28, 2018. In May 2020 and April 2023, the Board sought updated private treatment records from the medical providers the Veteran was regularly seeing for his psychiatric disorder. See Remand dated May 2020. The Veteran's private treatment records have been obtained and associated with the file. There has been substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In April 2023, the Board directed the AOJ to refer the Veteran's claim for TDIU prior to October 29, 2018, for extraschedular consideration by the Director of Compensation Service. See BVA Decision dated April 2023. The AOJ completed this in December 2023. As a result, the Board concludes that the prior remand directives have been substantially completed, and thus, VA's duty to assist the Veteran has been fulfilled. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall, D'Aries, and Dyment, all supra. Note to the Veteran: The Veteran was denied service connection for diabetes mellitus, type II, in an October 2017 rating decision for lack of a currently diagnosed disability of diabetes mellitus, type II. No appeal or supplemental claim has been submitted for that decision and it is beyond the scope of this appeal. The record does not currently reflect that the Veteran has a current diagnosis of diabetes mellitus, type II. If the Veteran has since been diagnosed with diabetes, the Veteran is encouraged to contact his representative in order to file a claim for service connection for diabetes mellitus, type II. Duties to Notify and Assist As an initial matter, in April 2023, a letter was sent to the Veteran asking him to complete VA Form 21-4142a, "General Release for Medical Provider Information to VA, VA form 21-4142, Authorization to Disclose Information to VA. See Subsequent Development Letter dated April 2023. In November 2023, another letter was sent to the Veteran requesting him to again complete VA Form 21-4142a, "General Release for Medical Provider Information to VA, VA form 21-4142, Authorization to Disclose Information to VA. See Subsequent Development Letter dated November 2023. However, the record does not show that the Veteran responded to any of the requests. As well, the record does not contain any indication that the requests were not received. See SSOC dated December 2023. The Board notes that the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190. 192 (1991). While VA does have a duty to assist the Veteran in the development of the claim, that duty is not limitless, and the Veteran must be prepared to cooperate with VA's efforts to obtain all relevant evidence. Olson v. Principi, 3 Vet. App. 480, 483 (1992). Here, however, the Veteran's failure to complete and return the forms in and of itself is not determinative. The Board does not find that it is deprived of its ability to best address the Veteran's TDIU claim. There is sufficient evidence in the record to substantiate whether the Veteran has been unable to obtain (secure) or maintain (follow) substantially gainfully employment prior to October 29, 2018. Neither the Veteran nor his representative have raised any concerns with VA's duties to notify or assist with regard to the issues of an initial increased disability rating for PTSD, with bipolar disorder and generalized anxiety disorder, and a TDIU. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board to search the record and address procedural arguments when the veteran fails to raise them before the Board."). Increased Rating Disability evaluations 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). 38 U.S.C. § 1155 (b); 38 C.F.R. § 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011). 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). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings be sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). 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. Where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board, however, retains the discretion to determine the credibility and probative value of all evidence of record, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). This benefit-of-the-doubt rule applies if the competing evidence is nearly equal but does not apply when the evidence persuasively favors one side or the other. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). The Board notes that it has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. Hence, the Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claims. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). For the entire period on appeal, the Veteran has been rated under Diagnostic Code (DC) 9411 for PTSD, which is evaluated under the General Rating Formula for Mental Disorders. 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). Under the General Formula, a 30 percent disability rating is warranted for 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 conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability 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. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self of others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Prior to October 29, 2018, an initial rating of 70 percent for PTSD with bipolar disorder and generalized anxiety disorder, is granted. The Veteran contends that his initial 30 percent rating for PTSD, with bipolar disorder and generalized anxiety disorder does not properly reflect his level of disability and he is entitled to a higher rating prior to October 29, 2018. See Notification Letter dated April 2020. The primary issue before the Board is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating greater than 30 percent. The Board ultimately concludes that the Veteran's symptoms more closely approximated the symptoms associated with a 70 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. The Veteran's treatment records show the Veteran has a history of PTSD and bipolar disorder, manifested by such symptoms as mood instability, anger, irritability, increased emotions, hopelessness and guilt, sleep disturbances, suicidal ideation, and decreased focus and concentration. See MTR dated March 2015; MTR dated September 2015; MTR dated June 2017; MTR dated November 2018; See DBQ dated May 2018. He was hospitalized for four days in August 2017 for manic episodes, irritability, and suicidal ideation, but he continued with symptoms of worsening sleep, restlessness, and poor memory. See MTR dated August 2017. In a March 2018 statement, the Veteran's wife stated that he has terrible nightmares, panic attacks, irritability, anger, depression, flashbacks, trouble adjusting, difficulty concentrating, angry outbursts and he is distant with family. She stated he was preoccupied with doing something wrong at work, fearing he would blow up his power plant. He additionally stopped playing tennis, despite his love for the game. See Buddy Statement dated March 2018. In a July 2017 Initial PTSD Disability Benefits Questionnaire (DBQ), the VA examiner diagnosed the Veteran with both bipolar disorder and PTSD. The examiner explained it is possible to differentiate what symptoms and level of impairment are attributable to each diagnosis. For PTSD, the examiner explained that the Veteran's symptoms would be anxiety and chronic sleep impairment, resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform tasks. For bipolar disorder, the examiner explained that the Veteran's symptoms would be impaired impulse control, impaired judgment, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances in a work or work-like setting, near continuous depression effecting ability to function appropriately, depressed mood, difficulty in understanding. The examiner explained that bipolar disorder would result in a level of impairment consistent with occupational and social impairment with deficiencies in most areas including work, school, family relations, judgment, thinking and or mood. The Veteran was emotionally labile with significant crying during the examination, had flight of ideas and tangential associations, grandiose thinking, and he had loud and rapid speech. He reported feelings of sadness and discouragement. See DBQ dated July 2017. In a May 2018 PTSD DBQ examination, the VA examiner diagnosed the Veteran with both bipolar disorder and PTSD. The examiner explained it is possible to differentiate what symptoms and level of impairment are attributable to each diagnosis. For PTSD, the examiner explained that the Veteran's symptoms would be anxiety, suspiciousness and chronic sleep impairment, resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform tasks. For bipolar disorder, the examiner explained the Veteran's symptoms would be depressed mood, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, impaired judgment and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner assessed, there is no objective medical evidence to suggest a direct causal link between in-service stressors and bipolar symptoms that started over forty years later. As such, the Veteran's PTSD and Bipolar Disorder are considered to be separate diagnosis and his bipolar disorder appears to be unrelated to his military service or PTSD. During the exam, the Veteran reported feeling depressed for the past month. He also reported irritability, difficulty concentrating, feelings of guilt, worthlessness and hopelessness, decreased engagement in previously enjoyed activities and depression. He reported difficulty falling asleep most nights. The physician concluded that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. See DBQ dated May 2018. In a November 2018 private PTSD DBQ, the private clinician diagnosed the Veteran with PTSD, Bipolar Disorder and generalized anxiety. The private clinician concluded; it is not possible to differentiate what symptoms are attributable to each diagnosis. The private clinician assesses the Veteran with the following symptoms: depressed mood, anxiety, panic attacks that occur weekly or less, chronic sleep impairment, mild memory loss, flattened affect, difficulty in understanding complex commands, impaired judgement, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, suicidal ideation, impaired impulse control, and intermittent inability to perform activities of daily living. The private physician assessed the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. See Private DBQ dated November 2018. In a February 2019 Review PTSD DBQ examination, the VA examiner agreed that because the Veteran's Bipolar I Disorder is currently in a depressed phase, this makes it particularly difficult to discern which symptoms are attributable to each mental disorder. Both of the Veteran's depressed episode (of his Bipolar I Disorder) and his PTSD have numerous overlapping symptoms, including depressed mood, sleep difficulties, memory problems, concentration problems, diminished interest in usual activities, low motivation, irritability, and relationship problems. As to the occupational impact of the Veteran's claimed mental disabilities the physician notes, Veteran is not currently working. He retired about six to seven years ago. Veteran has not had any additional education since his last evaluation. He currently works part-time for Aging Partners in David City, Nebraska. He works varying hours (as his mental health conditions permit) and does odd jobs such as shoveling snow, mowing the lawn, and picking up branches. This was suggested by veteran's counselor and psychiatrist, so he has something to do to get him out of the house and help with his depression. Veteran said he also likes to go to the library or senior center to get out of his home. None the less, the VA examiner assessed, at this time, the Veteran's symptoms are severe enough that he could not function successfully in an occupational environment. His symptoms of severe depression, memory problems, concentration problems, difficulty establishing and maintaining relationships, irritability, low motivation, and chronic sleep problems would prohibit him from being successful in a work environment. Veteran currently works part-time at Aging Partners, but he only does this work when he feels able (there are no set work hours). It is believed that veteran could not attend set work hours on a regular basis due to his current symptoms. The VA examiner concluded the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. See DBQ dated February 2019. As an initial matter, the Veteran was in receipt of a 30 percent disability rating for the service-connected psychiatric disorders from June 26, 2017, to October 28, 2018, under DC 9411. The evidence as reported above- and in the claim's file- warrants a 70 percent rating, not higher, for the PTSD, with bipolar disorder and generalized anxiety disorder. During the relevant time period on appeal, specifically from June 26, 2017, to October 28, 2018, the Veteran's service-connected PTSD, with bipolar disorder and generalized anxiety disorder manifested in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, which is contemplated by a 70 percent disability rating. 38 C.F.R. § 4.130. Although the Veteran's medical treatment records evince periods where the Veteran is sometimes functioning satisfactorily, with some routine behaviors, and self-care, there is no dispute that the severity, frequency, and duration of the Veteran's symptoms such as: depressed mood, sleep difficulties, memory problems, difficulty in understanding complex commands, impaired judgement, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, low motivation, irritability, hypervigilance, terrible nightmares, and suicidal ideations, begin prior to October 29, 2018. For example, the Veteran's psychiatric hospitalization for the above symptomology occurred in August 2017. See CAPRI dated August 2017. In addition, the Veteran has also shown symptoms not typically contemplated by the rating schedule, such as feelings of hopelessness, guilt, and irritability. The November 2018 private (PTSD) examination and the July 2017, May 2018, and February 2019 VA (PTSD) examinations are adequate for review. There is no evidence that the examiners were not competent or credible, and as the examination is based on the Veteran's statements, in-person examinations and the examiners' observations, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-05 (2008). The Veteran and the Veteran's wife are competent to report as to the observable events and symptoms he experiences and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds the Veteran and the Veteran's wife reported history to be credible. In this regard, the Veteran's service treatment records note psychiatric disorders, suicidal ideations, work history and other supporting details in the medical treatment records. There were four PTSD examinations of the Veteran. The VA provided PTSD examinations for the Veteran in July 2017, May 2018, and February 2019. A private physician conducted a PTSD examination in November 2018. The VA's PTSD examinations conducted in July 2017 and May 2018 found that the Veteran had more than one mental disorder and both VA clinicians assessed it is possible to differentiate what symptoms are attributable to each diagnosis. On the other hand, the private PTSD examination of the Veteran in November 2018 and the VA PTSD examination of the Veteran in February 2019 found that due to the overlapping symptomatology of the Veteran's multiple mental disorders, it is not possible to differentiate what symptoms are attributable to each diagnosis. The Veteran should have been rated on the totality of his psychiatric symptomatology, prior to October 29, 2018, pursuant to (1) the benefit of the doubt rule; and (2) Mittleider, which holds that when it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms should be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. at 182 (1998); see also 38 C.F.R. § 3.102. The medical evidence and lay statements demonstrate the severity, frequency, and duration of the Veteran's symptoms, such as suicidal ideation, depressed mood, anxiety, panic attacks that occur weekly or less, chronic sleep impairment, mild memory loss, flattened affect, difficulty in understanding complex commands, impaired judgement, disturbances of motivation and mood, impaired impulse control, and intermittent inability to perform activities of daily living more closely approximate occupational and social impairment, with deficiencies in most areas. This is consistent with a 70 percent disability rating prior to October 29, 2018. Based on the foregoing, and resolving all doubt in favor of the Veteran, the Board finds that the Veteran is entitled to a 70 percent rating for his PTSD with bipolar disorder and generalized anxiety disorder for the appeal period prior to October 29, 2018. Accordingly, the criteria for an increased rating of 70 percent for PTSD with bipolar disorder and generalized anxiety disorder, prior to October 29, 2018, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, DC 9411. An initial rating greater than 70 percent for PTSD with bipolar disorder and generalized anxiety disorder, is denied. The Veteran has a 70 percent disability rating for PTSD with bipolar disorder and generalized anxiety disorder for the entire period on appeal. The primary issue is therefore whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 100 percent. The Board ultimately concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 100 percent. The Veteran's symptoms more closely approximated the symptoms associated with a 70 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. The evidence as reported in the claims file does not warrant a rating greater than 70 percent rating, for the Veteran's PTSD, with bipolar disorder and generalized anxiety disorder for the entire period on appeal. During the relevant time period on appeal, the Veteran's symptoms did not cause total occupational and social impairment The Veteran maintains some social relationships with friends and family and is able to interact with medical providers without unnecessary social friction. See, e.g., MTR dated June 2015; MTR dated September 2015; MTR dated Feb 2017; Even if he does not extensively interact with them socially, his description of his interaction does not reflect impairment of such a severity and frequency indicative of a 100 percent rating, such as being a persistent danger to them, behaving inappropriately towards them, or hallucinating about them. Occupationally, the Veteran was still able to execute tasks, such as working odd jobs and working part-time at Aging Partners. See, e.g., MTR dated Feb 2017; MTR dated June 2016. This does not reflect impairment of such a severity and frequency indicative of a 100 percent rating, such as being disoriented to time or place or memory loss to the extent of being unable to recall his own name or others' close to him. The Veteran states that his mental condition is worsening. See DBQ dated February 2019. The Veteran is competent to report his symptoms, such worsening feelings of depression and becoming more distant and isolated. See Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board has reviewed the competent medical evidence of record and has determined there is insufficient competent or credible evidence of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self of others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name, at any point during the appeal period. McClain v. Nicholson, 21 Vet. App. 319 (2007). In light of the foregoing, the Board concludes that, as the evidence persuasively favors against the claim, it is not in approximate balance, and the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, 21 F.4 th 776 (Fed. Cir. 2021). Accordingly, the Board finds, the criteria for an increased rating of 70 percent for psychiatric disorders (claimed as posttraumatic stress disorder (PTSD) with bipolar disorder and generalized anxiety disorder), but not higher, from October 29, 2018, to present have not been met. 38 U.S.C. §§ 1131, 1110, 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, DC 9411. TDIU To establish entitlement to a TDIU, there must be impairment so severe that it is impossible for the Veteran to secure or follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. The term "substantially gainful occupation" is not defined in the rating schedule. Rather, the holding in the case of Ray v. Wilkie, 31 Vet. App. 58 (2019) defined the term "unable to secure and follow a substantially gainful occupation" as having two components: one economic and one noneconomic. The non-economic component includes consideration of the following: the Veteran's history, education, skill, and training; whether the Veteran has the physical ability (both exertional and non-exertional) to perform the type of activities required by the occupation at issue; and whether the Veteran has the mental ability to perform the activities required by the occupation at issue. Such specific physical ability-factors include lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory, and visual. Specific mental ability-factors include memory, concentration, ability to adapt to change, handle work-place stress, getting along with coworkers, and demonstrating reliability and productivity. Id. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. Marginal employment shall not be considered substantially gainful employment and generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16. The Court has defined "employment in a protected environment" as "a lower-income position that, due to the veteran's service-connected disability or disabilities, is shielded in some respect from competition in the employment market." LaBruzza v. McDonough, 2024 U.S. App. Vet. Claims LEXIS 72 (Jan. 24, 2024). The Board may consider the nature, length, and reason for termination of employment when assessing whether that employment was in a protected environment. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Factors such as the type and extent of accommodations received, the employer behavior or intent toward the veteran, and whether the veteran's income is significantly above the poverty threshold can be considered but are not dispositive. See LaBruzza; Arline v. McDonough, 34 Vet. App. 238 (2021) (Bartley, J., dissenting in part). However, receiving an accomodation pursuant to the Americans with Disabilities Act is not being shielded from competition in the employment market because it is a feature of the employment market. See Labruzza, supra. The central inquiry in a claim for a TDIU is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The ultimate question of whether a Veteran is capable of substantially gainful employment is not a medical one; that determination instead is for the adjudicator. See 38 C.F.R. § 4.16 (a); see also Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376 (2013). A veteran is eligible for a schedular rating of TDIU if either one service-connected disability is rated at least 60 percent or multiple service-connected disabilities yield a combined rating of 70 percent (with at least one of those disabilities rated 40 percent or more). 38 C.F.R. § 4.16 (a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple disabilities incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16 (a). If, however, the Veteran does not meet these required percentage standards set forth in 38 C.F.R. § 4.16 (a), he still may receive a TDIU on an extraschedular basis if it is determined that he is unable to secure or follow a substantially gainful occupation by reason of his service-connected disabilities. 38 C.F.R. § 4.16 (b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, there must be a determination as to there must be a determination as to whether there are circumstances in this case, apart from any non-service-connected conditions and advancing age, which would justify a total rating based on unemployability. See Hodges v. Brown, 5 Vet. App. 375 (1993). Entitlement to a total disability rating based on individual unemployability, prior to October 29, 2018, is granted. Schedular TDIU is warranted because the Veteran is unable to obtain and maintain a substantially gainful occupation due to his service-connected PTSD with bipolar disorder and generalized anxiety disorder. Service connection has been established for PTSD with bipolar disorder and generalized anxiety disorder, rated 70 percent disabling from June 26, 2017; Splenectomy with scarring, rated 30 percent disabling from June 19, 1970; tinnitus, rated as 10 percent disabling from June 2017; and erectile dysfunction, rated as noncompensable from June 26, 2017. The Veteran's single 70 percent rating for PTSD with bipolar disorder and generalized anxiety disorder meets the requirement for a schedular TDIU. 38 C.F.R. § 4.16(a). Because the Veteran is precluded from obtaining and maintaining a substantially gainful occupation due to bipolar disorder and generalized anxiety disorder alone, the Board will focus on the evidence relating to this disability. The Veteran is a high school graduate. A July 2017 VA PTSD examination noted that the Veteran competed high school and denied any college, technical, or trade school. The veteran was employed at a packing house after the service for 13 to 14 years (Cargill Meat Solution). The veteran worked for the City of David City, and he was an operator at the Power Plant. He took care of the engines and read the meters. He was with the City of David City for just about 27 years. See DBQ dated July 2017; See VA 218940 dated November 2018. In evaluating the Veteran's ability to find work, the Board finds that the Social Security Administration's (SSA) regulations and rulings unrelated to age to be highly probative and will consult them. See Ray v. Wilkie, 31 Vet. App. 58 (2019). As noted in Social Security Ruling (SSR) 85-15 : the basic mental demands of competitive, remunerative, unskilled work include the abilities (on a sustained basis) to understand, carry out, and remember simple instructions; to respond appropriately to supervision, coworkers, and usual work situations; and to deal with changes in a routine work setting. A substantial loss of ability to meet any of these basic work-related activities would severely limit the potential occupational base. This, in turn, would justify a finding of disability because even favorable age, education, or work experience will not offset such a severely limited occupational base. The evidence suggests that the Veteran's service-connected PTSD with bipolar disorder and generalized anxiety disorder adversely impacted the Veteran's ability to work. For example, in all three VA PTSD DBQ examinations, the VA examiners assessed that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The VA examiners assessed that the Veteran had the following symptoms: manic episodes, depressed mood, sleep difficulties, memory problems, concentration problems, diminished interest in usual activities, low motivation, and irritability among other issues. See DBQ dated July 2017; See also DBQ dated February 2019. The VA examiner in the February 2019 DBQ, further explained that "at this time, the Veteran's symptoms are severe enough that he could not function successfully in an occupational environment. His symptoms of severe depression, memory problems, concentration problems, difficulty establishing and maintaining relationships, irritability, low motivation, and chronic sleep problems would prohibit him from being successful in a work environment. Veteran currently works part-time at Aging Partners, but he only does this work when he feels able (there are no set work hours). It is believed that veteran could not attend set work hours on a regular basis due to his current symptoms." See DBQ dated February 2019. In March 2018, the Veteran's wife provided firsthand knowledge as to why the Veteran departed the workforce in 2012. The Veteran's wife reported the Veteran was worried he would do something wrong at work. The Veteran formerly worked at a power plant (the power plant had big engines). See VA Form 21-8940 dated November 2018. The Veteran was scared he would blow something up and people would be hurt (like the people in Vietnam) and it would be his fault. See Buddy Statement dated March 2018. In November 2018, the Veteran completed a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. The Veteran explained that he retired from his job early because he couldn't do his job anymore. "He could not sleep because of the stress of the job, couldn't concentrate, anxiety problems, difficulty understanding complex commands, missed work because of the thoughts and stress of the job." See VA Form 21-8940. A review of the Veteran's November 2018 application for a TDIU reveals the Veteran has been working part-time since 2015, and reportedly earning no more than $80 a month. Furthermore, his treatment records reveal he was hospitalized for four nights in August 2017 due to his psychiatric disability. See MTR dated August 2017 The July 2017, May 2018, and February 2019 VA examinations are adequate for review. There is no evidence that the examiners were not competent or credible, and as the examination is based on the Veteran's statements, in-person examinations and the examiners' observations, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-05 (2008). The Veteran and the Veteran's wife are competent to report as to the observable events and symptoms he experiences and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds the Veteran and the Veteran's wife reported history to be credible. In this regard, the Veteran's service treatment records note mental health symptoms with regard to his inability to concentrate, process information, complete task and his work history. Accordingly, the Board assigns their statements substantial probative weight. The RO has already conceded that the Veteran could not work since October 29, 2018, due to the Veteran's service-connected disabilities and established entitlement to TDIU as of October 29, 2018. Having reviewed all of the competent and credible lay and medical evidence of record and resolving the benefit of the doubt in the Veteran's favor, the Board finds that the evidence supports a finding that the Veteran's service-connected psychiatric disabilities alone rendered him unable to obtain or maintain substantially gainful employment from June 26, 2017. Accordingly, the criteria for TDIU prior to October 29, 2018, have been met. 38 U.S.C. § 1155 5107, 5110; 38 C.F.R. §§ 3.102, 3.340, 4.3, 4.16. Stephen F. Keane Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ridley, Reshae L. 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.