Citation Nr: 25004048 Decision Date: 03/25/25 Archive Date: 03/25/25 DOCKET NO. 13-21 939 DATE: March 25, 2025 ORDER Entitlement to an initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted from June 9, 2009, to April 17, 2018. Entitlement to a rating in excess of 70 percent for PTSD from April 18, 2018 is denied. Entitlement to a total disability rating based on individual employability (TDIU) is granted from June 9, 2009. Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(s) (SMC(s)) is granted for the entire period on appeal. FINDINGS OF FACT 1. From June 9, 2009 to April 17, 2018, the symptoms of the Veteran's PTSD disability more closely approximates occupational and social impairment with deficiencies in work, family relations, judgment, thinking, and mood; total impairment has not been shown at any point. 2. From April 18, 2018, the symptoms of the Veteran's PTSD disability more closely approximates occupational and social impairment with deficiencies in work, family relations, judgment, thinking, and mood; total impairment has not been shown at any point. 3. Resolving reasonable doubt in favor of the Veteran, his service-connected PTSD prevented him from securing or following substantially gainful employment from June 9, 2009. 4. From June 9, 2009, forward, the Veteran is in receipt of TDIU based solely on his service-connected PTSD and is in receipt of a 100 percent disability rating for his service connected bilateral upper and lower peripheral neuropathy disabilities which are separate and distinct and involve different anatomical segments or bodily systems from his PTSD. CONCLUSIONS OF LAW 1. From June 9, 2009, to April 17, 2018, the criteria for entitlement to a 70 percent rating, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.130, Diagnostic Code (DC) 9411. 2. From April 18, 2018, the criteria for entitlement to a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.130, DC 9411. 3. From June 9, 2009, the criteria for a TDIU rating have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 4. The criteria for entitlement to SMC(s) have been met for the entire period on appeal. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. § 3.350(i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran honorably served in the United States Army from December 1967 to August 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Historically, the Veteran's June 2009 informal claim of entitlement to service connection for PTSD was granted in a March 2010 rating decision and assigned a 10 percent rating. In a June 2013 rating decision, his initial disability rating was increased to 30 percent from August 25, 2013, forward. The Veteran perfected his appeal for an increased rating to the Board, and his claim was remanded in a September 2015 decision for further development, including obtaining the Veteran's medical treatment records from the Fayetteville Vet Center in Arkansas. In February 2018, the Veteran obtained his records from the Fayetteville Vet Center from April 2010 to January 2018 and associated them with his claims file. See February 2018 Medical Treatment Record -Non-Government Facility. In a May 2018 rating decision, the Veteran was granted a 70 percent disability rating, TDIU, and Dependents Educational Assistance (DEA) benefits effective April 18, 2018. In a September 2018 decision, the Board denied an earlier effective date prior to June 9, 2009, for the award of service connection for PTSD and remanded his claims for an increased disability rating to obtain outstanding mental health treatment records. In a December 2021 decision, the Board granted the Veteran an initial rating of 50 percent prior to April 18, 2018, and denied a rating in excess of 70 percent thereafter. The Veteran appealed the December 2021 decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2022 Order, the Court granted an October 2022 Joint Motion for Partial Remand (JMPR) and remanded the Veteran's claims for increased ratings to the Board. Specifically, the Court noted that a January 2018 Veteran Center progress note stated that the Veteran will return for group therapy on the next scheduled date. Further, a May 2018 VA primary care note reflected that the Veteran was followed at the mental health clinic. As the evidence indicated the Veteran received treatment at VA facilities after April 2018, the parties agreed that the Board erred in failing to ensure that all outstanding Veteran Center and VA treatment records were obtained. The Board remanded the Veteran's claims for increased disability ratings in February 2023 to obtain his outstanding medical treatment records after April 18, 2018. In a September 2024 rating decision, the RO issued a rating decision which continued the Veteran's 70 percent rating and found that his claim of entitlement to a TDIU was moot. In an October 2024 rating decision, the RO found that it had issued the September 2024 rating decision in error as the Veteran's claim was currently pending before the Board. In October 2024, the Veteran's prior representative requested a 90-day extension of time to procure additional evidence before the Board adjudicated the merits of the Veteran's claims. See October 2024 Third Party Correspondence. The Veteran's request for an extension was granted by the undersigned Veterans Law Judge (VLJ) in a November 2024 letter. See November 2024 BVA Letter. The Veteran submitted additional evidence in February 2025, the 90-day period has since expired, and the Veteran has not requested another extension. The Veteran's prior representative waived consideration of the evidence of record by the RO in a September 2024 Correspondence and a February 2025 Appellate Brief. Before proceeding to the merits of the appeal, the Board turns to address the October 2022 JMPR and the Board's February 2023 remand directives. Careful analysis shows that the Veteran obtained a portion of his medical records from the Little Rock Vet Center and associated them with his claims file. See March 2023 Medical Treatment Record -Non-Government Facility (Little Rock Vet Center Records). The available records are from February 2022 to March 2023. Attached to the records is a letter from the Little Rock Vet Center Director which stated, in sum, that the Veteran was a current client of Little Rock Vet Center, he had been seen an average of twice monthly since his transfer in February 2022, was previously seen by the Fayetteville Vet Center since April 7, 2010, and that the two facilities had recently merged. The RO stated in an August 2023 subsequent development letter to the Veteran that "[t]he note also mentions that you have been receiving care at the prior facility, Fayetteville Vet Center until the transfer. Previous Vet Center records end in 2018. We need to determine where the records from 2018-2022 are located." In response to this letter, the Veteran provided two VA Forms 21-4142, Authorizations for Release of Information, for the two Vet Clinics located in Little Rock and Fayetteville, Arkansas where he received treatment. See September 2023 VA Form 21-4138, Statement in Support of Claim; September 2023 VA Form 21-4142, Authorization for Release of Information. The RO sent letters in October and December 2023 to the Fayetteville Vet Center. Letters were also sent to the Little Rock Vet Center in October, November, and December 2023. A response was not received from either facility. The RO sent the Veteran a final attempt letter in January 2024 stating that his records from the Little Rock and Fayetteville Vet Centers could not be obtained and further results would be futile. The Board has carefully considered VA's duty to assist, the October 2022 JMPR, and the Board's February 2023 remand directives. 38 U.S.C. § 5103, 5103A; 38 C.F.R. § 3.159; Sullivan v. McDonald, 815 F. 3d 786, 793 (Fed. Cir. 2016); Stegall v. West, 11 Vet. App. 268, 271 (1998) ("[A] remand by this Court or the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders."). The RO made attempts to obtain the Veteran's outstanding treatment records and then notified him that his records were unavailable pursuant to 38 C.F.R. § 3.159. As shown by the nearly 16-year procedural history of this case, remanding the Veteran's claims to obtain the records can delay the appeal for years without an effective resolution. Weighing in favor of the Board proceeding without the records is the Veteran's request, through his previous representative, that it adjudicate the claims based upon the current evidence of record. See May 2024 and February 2025 Appellate Briefs. Thus, while the Board is cognizant that the records specifically requested in the October 2022 JMPR and the Board's February 2023 remand directives remain outstanding, it will not place the burden on the Veteran for the fact that the RO did not obtain his outstanding treatment records. Rather, the Board finds that there is other lay and medical evidence in the record sufficient to decide the claim on the merits and will infer that any missing information would support the Board's findings as further discussed below. The Board will thus proceed to the merits of the Veteran's claims. The Board has thoroughly reviewed the evidence of record in conjunction with this case. However, it has limited its discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Thus, the Board will summarize the relevant evidence where appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims on appeal. 1. Entitlement to an initial rating of 70 percent, but no higher, for PTSD is granted from June 9, 2009, to April 17, 2018. 2. Entitlement to a rating in excess of 70 percent for PTSD from April 18, 2018, is denied. 3. Entitlement to TDIU is granted from June 9, 2009. 4. Entitlement to SMC(s) is granted for the entire period on appeal. The Veteran contends that his PTSD is more severe than initially rated throughout the period on appeal and that his PTSD was of such severity to preclude employment on its own. See May 2024 Appellate Brief, February 2025 Third Party Correspondence, and February 2025 Appellate Brief. The Veteran is currently in receipt of a 50 percent rating from June 9, 2009, to April 17, 2018, and a 70 percent rating from April 18, 2018, forward. 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. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. 38 U.S.C. § 1155. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id.; see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The determination of whether an increased disability rating is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board considers not only the criteria of the currently assigned DCs, but also the criteria of other potentially applicable DCs. 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. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." See 38 U.S.C. § 1155; Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different DCs. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). In deciding an appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination about the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a Veteran's disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. at 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr, 21 Vet. App. 308. After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). The Veteran's PTSD has been evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411. Under DC 9411, a 50 percent evaluation is warranted where there is 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is objective evidence demonstrating 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 that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or 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; and the inability to establish and maintain effective relationships. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior; persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time and place, and memory loss for names of close relatives, own occupation, or own name. Evaluations under § 4.130 are symptom-driven, meaning that symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). Severity and duration of the symptoms also play an important role in determining the rating. Id. at 117. The Board notes however that the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating and are not meant to be exhaustive. The Board need not find all or even some of the symptoms to award a specific rating. 38 C.F.R. § 4.21; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions will be equitable and just as contemplated by the requirements of the law. 38 C.F.R. § 4.6. In assigning the Veteran's disability rating, the Board will also consider whether his PTSD disability, on its own, was of such severity as to totally preclude employment warranting a grant of SMC(s). See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding inferred TDIU claims are part and parcel of underlying increased rating claim); Bradley v. Peake, 22 Vet. App. 280, 293 (2008); Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); 38 U.S.C. § 1114, 38 C.F.R. § 3.350(i). Given that the issue of entitlement to a TDIU came to the Board as part and parcel of his claims for higher disability ratings for his PTSD, the date of claim for his entitlement to a TDIU therefore begins June 9, 2009. Id. Total disability will be considered to exist where there is present an impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. 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 the Veteran's age or the impairment caused by any nonservice-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation because of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, the disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and enough additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In determining whether a Veteran can secure and follow a substantially gainful occupation, attention must be given to the Veteran's history, education, skill, and training; whether the Veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the Veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and whether the Veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the Veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). However, the responsibility for making the ultimate TDIU determination is placed on the adjudicator and not a medical examiner, rather, a medical examiner's role is limited to describing the effects of disability upon the person's ordinary activity. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The finding of an ability to work is not a medical determination, but is a legal determination made on a case-by-case basis. See Withers v. Wilkie, 30 Vet. App. 139 (2018); Geib, 733 F.3d at 1354. This decision is based on a review of medical and lay evidence presented in light of each Veteran's education, training, and work history. Id. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (the benefit-of-the-doubt rule applies if the competing evidence is in approximate balance). In applying the benefit of the doubt rule, the Board is required to assign probative weight to relevant evidence, make a specific finding as to which evidence the Board finds more persuasive, and provide the reasoning for such finding. Bufkin v. McDonough, 75 F.4th 1368 (Fed. Cir. 2023). All medical definitions utilized herein may be found at Dorland's Medical Dictionary Online. The Board will chronologically address the relevant lay and medical evidence of record to support its findings below. In a June 2009 lay statement, the Veteran's wife wrote: In April 2002, my husband began having medical problems. He was having to leave work early and missing work some days -very, very unlike his work ethics. In 2005 he was forced to file disability with Social Security. Headaches have kept him confined from 1-2 weeks. His leg would give way completely causing him to fall and this happened frequently. Now they swell, especially his left one; so do his hands and arms. At times he cannot drive, do any chores, or go anywhere. It has been my responsibility to drive him to his doctor appointments or places we need to go. He gets very forgetful. He seems to not want to think. He gets lethargic easily. He becomes withdrawn and non-communicative. His reasoning can be so complex. When he has felt well enough to do chores or work on projects, he is in so much pain when he stops working on them. Many nights, he hardly sleeps or he has nightmares. I can hear him yell or be flailing his arms and legs. Due to these episodes, we are no longer able to sleep together. His disabilities cause frustration and is stressful for the both of us. See June 2009 VA Form 21-4138, Statement in Support of Claim. In a July 2009 VA 21-0781, Statement in Support of Claim for PTSD, the Veteran described having nightmares and flashbacks as a result of his PTSD. The Veteran stated that his PTSD affected his everyday life and marital relationship. See July 2009 VA Form 21-4138, Statement in Support of Claim. In a July 2009 VA Form 21-4142 Authorization for Release of Information, the Veteran stated that he had received treatment for depression since May 2005 and that that year, he had to increase the dosage of his psychiatric medication. In a July 2009 VA Form 21-527, Income-Net Worth and Employment Statement, the Veteran stated that he had lost 45 days of work in the last year as a result of his service-connected disabilities. The Veteran also reported completing an eighth grade education, vocational school for plumbing, that he left his position as a journeyman plumber in 2004, and was in receipt of Social Security disability. Id. In an August 2009 lay statement, the Veteran's son described his father's PTSD: This letter is in reference to my Dad and how his disability has affected him. My experience as a paramedic and an emergency room RN has given me the ability to assess and observe how his disability has affected his life and those close to him. I can see the frustration in him knowing that he is unable to do the things he used to do. The pain he experiences often clouds his judgment and decision-making abilities. Sometimes he has to rely on others for assistance in doing the simplest of tasks. He is often unable to focus, concentrate, and even function due to the pain. Examples are: reading a tape measure correctly, climbing a step ladder, using a power tool, driving, and even walking short distances. (these are only a few). On many occasions, I have seen the pain, headaches, and extreme swelling confine him to the bed. This is not only frustrating for him, but for my Mother - who he has to rely on for assistance - and others. Imagine being in constant pain and unable to perform normal activities of daily living that many of us take advantage of. I hope this letter can give you some insight on how this disability has affected my Dad, my Mother, Myself, and Others. See August 2009 VA Form 21-4138, Statement in Support of Claim. The Veteran further described having excessive memory loss, flashbacks, disturbances of motivation and mood, and sleep impairment and reiterated that his PTSD "extremely" affected his everyday life and marital relationship. See August 2009 VA Form 21-4138, Statement in Support of Claim. The Veteran was afforded a VA examination in November 2009. See November 2009 C&P Exam (November 2009 Initial PTSD Exam). Therein, the examiner diagnosed the Veteran with PTSD and noted his reports that "I can't sleep. I have a lot of nightmares." The Veteran described that he had nightmares two or three times a night which would awaken him and there were times when he could not return to sleep. The Veteran further described getting three to four hours of sleep per night. The Veteran reported that he tried to stay busy during the day, but sometimes would think about his experiences in the military. The Veteran described being easily startled by jets and fighter planes, that when out to dinner with his wife, he would typically sit in the corner, and that when he went to large stores he would typically wait in the car while his wife shopped. The Veteran further stated that he avoided watching any news about war. The Veteran reported that he had been married to his wife for 42 years, that he felt close to her and that they got along well, although "we can't sleep together anymore because I beat her up at night." The Veteran further reported retiring about five years prior after working for the same company as a plumber for about 30 years, that he retired because of his bilateral upper and lower extremity peripheral neuropathy, and that he was currently in receipt of Social Security Administration (SSA) Disability benefits for same. The Veteran stated that he enjoyed completing wood projects and camping, that he attended church, and visited with other Veterans. Upon mental status examination, the examiner noted that the Veteran was casually groomed, fully cooperative, and his speech and behavior were within normal limits. The Veteran's mood was generally euthymic (defined as a mood that is neither elevated nor depressed), and his affect was appropriate to content. His thought processes and associations were logical and "tight." "No loosening of associations" were noted, nor was any confusion. His memory was grossly intact, and he was oriented to all spheres. The Veteran did not report hallucinations and no delusions were noted. The Veteran's insight and judgment was noted as adequate. The Veteran denied suicidal or homicidal ideation. The examiner commented that the "[f]requency of symptoms as reported by the Veteran is as noted above. I believe these symptoms are mild. They have persisted for many years... I did not find any evidence that PTSD symptoms negatively impact employment in any way. No impairment and thought processing or communication was noted. I did not find evidence of another psychiatric disorder in today's examination." In an August 2010 letter, the Veteran's wife stated: His symptoms of PTSD has worsened within the last year. How? 1. He has admitted to me before that he has thoughts of suicide. Observing him in depressed moods recently, I've asked him what he was thinking, and I have asked him repeatedly but my questions go unanswered. 2. He reverts to listening to audio cassettes/CDs or watches TV to avoid communicating. Numerous times, he tries to avoid talking to family, friends, and me and doesn't want to be around them. 3. If he is working on a particular project, he is obsessed with completing it and does not want to take breaks or take time to eat. 4. When he communicates with me, the things he says are not logical in relation to the subject we're discussing nor are they relevant. Certain questions I may ask him, his answers are not relevant or logical in relation to what I asked him. He never asked questions, e.g. do we need anything, can I help you with anything, can you help me with this, etc. Some certain things, especially personal matters, he refuses to comment and quickly changes the subject. Frequently, in decision making matters, he leaves it up to me and becomes uncommunicative and persistence fails. Later, he becomes critical of my decisions. 5. He feels the need to go into town daily. A round trip for us is 32 miles (not counting miles we drive around town). It is my responsibility to keep control of our finances because he doesn't realize the difference between our needs and wants financially. He is paranoid about being late for his appointments and we leave home much too early. 6. He neglects his appearance by not combing his hair and it doesn't bother him if his clothes are disheveled or how they look, e.g. they may be wrong side out or wrinkled, etc. When he undresses he just wants his clothes up. 7. Around crowds of 6 to more people, he becomes agitated and panicky; We have to leave. He forgets where the entrances slash exits are. This applies to group meetings, functions, the VA outpatient clinic at Little Rock, and other. This has forced us to drop out of all of our activities. 8. Impairment of memory - he forgets to do even the minor chores, closing, locking or unlocking doors and gates, turning off lights, putting equipment or tools away, leaving keys in the ignitions, turning off outside hydrants, putting things back in their proper places, feeding and watering our pets, throwing things down anywhere and doesn't bother to pick them up, etc. 9. I do 90% of our driving because of his driving ability. 10. For some other things, judgments he doesn't make any sense at all (as so do others think too). 11. He makes plans to work on a certain thing or project and soon he changes his mind and does something else. He's happy at the moment, then in a matter of a few minutes, he's quiet and may stare into space. He's real energetic, then a matter of minutes, he sits down. He has an opinion one day and the next day it is different. He makes remarks then later he denies saying them. He's lost interest with so many areas of our lives and other things. 12. I constantly have to repeat myself. He does not understand or grasp what I say. He also ignores what I say. 13. He gets very argumentative with me often. 14. He is not the loving person he used to be toward me, our son, and our grandchildren. 15. His PTSD has affected our relationship extremely. Over seven years now, we are unable to sleep together. Numerous nights after we go to bed, I hear him yell or talking, flailing his arms are kicking his feet before I go to sleep. He also wakes me up doing these. I wake him up but he won't/can't tell me what his nightmares are about or what is making him so restless. Days later, he may ask me if I heard gunshots or other - of which there were no gunshots or any other kinds of noises. To sum it up [the Veteran's] PTSD is very stressful, worrisome, unsatisfactory, and causes hardships for the both of us. See August 2010 Buddy/Lay Statement. The Veteran's son also expressed his observations in an August 2010 letter: My experience as a paramedic and RN gives me the ability to observe and assess his PTSD. His logic of thinking has worsened within the past year. His responses are often extremely difficult for me to understand. Numerous times I have seen him confined to bed or unable to function because of sleep deprivation, pain, headaches, and swelling; also, unable to concentrate or make sound decisions. Not only are these abnormalities frustrating for him but for my Mom-his caregiver whom he has to rely on- family and friends. See id. In a June 2010 letter from a social worker at the Fayetteville, Arkansas Vet Center, the Veteran's readjustment counselor stated that the Veteran had been receiving treatment since April 2010. See August 2010 Medical Treatment Record - Government Facility. Therein, the social worker stated that the Veteran endorsed intrusive thoughts, issues with anger and irritability, feelings of nervousness and anxiety, hyper alertness, and a sense of loss of control when faced with stress or anxiety. The social worker stated that the Veteran's symptoms greatly interfered with his relationships and caused him difficulties in social venues. In a November 2010 VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, the Veteran reported that his PTSD and peripheral neuropathy disabilities prevented him from securing of following any substantially gainful occupation. In the remarks section, the Veteran noted "[m]y PTSD is getting worse - I am unable to sleep, concentrate, and function like I need to each day and get very depressed often. I am in constant pain all of the time." In a December 2010 VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability, the Veteran's previous employer noted that he worked as a plumber from November 1969 until September 2005 and that "we did not terminate him, he quit because of his health." In response to the prompt "concessions, if any made to employee by reason of age or disability," the Veteran's employer stated "[h]e was allowed to work, performing duties he was able to." In a June 2012 letter to the President of the United States, the Veteran's wife stated that his condition was worsening. See June 2012 Buddy/Lay Statement. The Veteran underwent a second VA examination in April 2013. See April 2013 Review PTSD Exam Disability Benefits Questionnaire (DBQ). Therein, the Veteran reported that he worked as a plumber until 2005 when he had to quit due to physical problems. The Veteran stated that he attended group therapy at the vet center and took prescription medication for his PTSD disability. The examiner diagnosed the Veteran with PTSD and found that the Veteran experienced persistently experienced the PTSD-related traumatic events in the form of recurrent distressing dreams, and that he would engage in persistent avoidance of stimuli associated with the PTSD-related traumatic events and numbing of general responsiveness which were exhibited by his efforts to avoid thoughts, feelings, or conversations associated with the PTSD-related traumatic events, efforts to avoid activities, places, or people that aroused recollections of the PTSD-related traumatic events, and feelings of detachment or estrangement from others. The examiner further found that the Veteran experienced persistent symptoms of increased arousal as indicated by his difficulty falling or staying asleep, irritability or outbursts of anger, and exaggerated startle response. The examiner indicated that the Veteran's PTSD symptoms, including anxiety, chronic sleep impairment, and disturbances of motivation and mood caused clinically significant distress or impairment in social, occupational, or other important areas of functioning and concluded that the Veteran's PTSD resulted in occupational and social impairment with an 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. A complete copy of the Veteran's medical treatment records from April 2010 to January 2018 from the Fayetteville Vet Center were associated with his claims file in February 2018. See February 2018 Medical Treatment Record-Government Facility. A thorough review of the records reveals the Veteran's reports of depression, anxiety, anger, irritability which increased around groups of people, marital strife, nightmares, the use of avoidance to maintain safety and insulate himself from painful feelings, intrusive thoughts, and flashbacks. Careful analysis of the individual and group encounters from April 2010 to January 2018 shows that the Veteran's behavior, thought processes, and participation in group and individual therapy was consistently noted as logical, appropriate, and coherent and do not contain any findings or reports of suicidal or homicidal ideation or thoughts, gross impairment in thought processes or communication; persistent delusions or hallucinations, grossly inappropriate behavior, that the Veteran was a persistent danger of hurting himself or others, the intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time and place; and memory loss for names of close relatives, own occupation, or own name. The Veteran was afforded a third VA examination in April 2018. See April 2018 C&P Exam (April 2018 Review PTSD DBQ). Therein, the examiner diagnosed the Veteran with both PTSD and major depressive disorder (MDD) and indicated that the Veteran's MDD was due to the Veteran's physical health problems arising from his peripheral neuropathy, skin problems, headaches, sleep apnea, and heart conditions that he described as affecting his day-to-day functioning or requiring the use of daily medication or medical devices. The examiner noted that "these conditions can co-occur, and there is some overlap in their symptoms and associated features, which precludes attribution of certain specific difficulties to one condition or another without resorting to speculation. Consequently, these conditions cannot be fully differentiated from each other." Therein, the Veteran reported that he lived in Arkansas with his wife of 50 years. He described his home life as "pretty rough for her the past few years. Putting up with me. I guess I get pretty violent in my sleep, bang her around. I bruise her up pretty good, I guess. We haven't been able to sleep together for years. Sometimes I'll get into a zone where she can't get my attention, and she gets pretty angry. I'll be awake. I just zone out. I'm not even aware I'm doing it." The Veteran detailed that he had a son but that two of his children were deceased, three grandchildren and five great-grandchildren. "It's a mess when they're there. The noise. I hate crowds." The Veteran stated that he "[a]lways stayed away from other people after I got back" but he had one friend with whom he served in Vietnam and that he used to go camping with him pretty regularly. The Veteran detailed that he went to church every Sunday, and that it was a "[s]mall church. About 25 people. It's not too noisy." The Veteran reported that he sometimes went camping with his son and "[t]hat's about the only time I can really rest." The Veteran stated that he liked to tinker with his old Mustang, used to like hunting but no longer did so, and that he and his wife drive around sightseeing because she likes to take pictures of scenery. The Veteran reported that he was a plumber for over 30 years and retired in 2005, detailing that "I had to quit. I kept falling off buildings. I have neuropathy real bad in my legs." The Veteran reported that he had no problems at work, noting that "I worked way out, in a house, just me and another guy. Peaceful and quiet. I worked almost 15 years without taking a day off." The Veteran stated that he attended a PTSD support group twice a month and that "[i]t helps to talk to people who've been there. They've done more for me than the [private providers] I went to before, and I was paying to see them." The Veteran reported taking prescription medication for his PTSD-related headaches, itching, and nightmares but that "I don't take it unless I just have to." The Veteran described his sleep impairment, noting "I don't sleep much. Sometimes I don't sleep at all, sometimes I'll get two or three hours." The Veteran reported sleeping on the back porch for years, until he started having heart problems and his wife made him move back inside and that "I haven't slept good since. I feel tired all the time." The Veteran described waking up when he heard noises at night, or when he feels vibrations from nearby trains, detailing that "[i]t's like when the ground was vibrating [from explosions] over there." The Veteran stated that his appetite was diminished, noting that "I eat maybe one meal a day. I just don't get hungry." The Veteran stated he had issues with concentration and memory, stating that "I have trouble paying attention to what's going on" and "we'll be talking about a place we've been, and I know it, but I can't recall [the name]. My wife'll get onto me for not remembering to do something she asks me to do." The Veteran described his disturbances in motivation and that his mood was apathetic, detailing "like I don't give a crap about things. I don't feel like doing anything, or want to do anything. Just get out and be by myself. I feel guilty a lot. When I think about my kids and stuff. I brought all that junk back with me [from Vietnam]." The Veteran expressed feelings of guilt, nervousness, stress, and worry. The Veteran described his anger problems, noting that "I have to try to keep from getting angry, because if I get angry, I can't control it. If I feel like I'm getting mad, I have to get away. So I usually walk away from it. I can get violent at times, and I don't want to do that. So I stay away from it." The Veteran stated that he had nightmares related to his Vietnam experiences "pretty often. Might go for a month or 2 [without having them], and all of a sudden, something'll cause me to have them. It just happens." The Veteran detailed that he had intrusive thoughts, memories, and dreams related to his service in Vietnam. The Veteran described physical triggers, such as the smell of diesel fuel. He stated that he tried to read a book on Vietnam, but "I got a couple of pages in, and had to send it back." The Veteran described his feelings of hypervigilance, but "[i]t's not all the time" and that he prefers to go shopping early in the morning or late at night. The examiner noted that the Veteran's appearance was unremarkable, and his grooming and hygiene were appropriate. He was alert and oriented to person, place, time, and situation. The examiner remarked that while no formal evaluation of his mental status was conducted, his cognitive functioning appeared to be adequately intact for the purpose of the interview. The Veteran verbalized understanding of the nature and purpose of the evaluation, the examiner's role in the disability claims adjudication process, and the limits of confidentiality. The examiner indicated that the Veteran's engagement was satisfactory, and his responses to inquiries were appropriate in content and level of detail. The Veteran's speech was clear and intelligible, and of normal rate, volume, and prosody (defined as the variation in stress, pitch, and rhythm of speech by which different shades of meaning are conveyed). The examiner found that there was no evidence of significant expressive or receptive language impairments, that the Veteran's thoughts were logical, coherent, and goal-directed, and there was no overt evidence of perceptual disturbances, delusional beliefs, or perseverative thoughts. The examiner noted that the Veteran's attention, concentration, and motor activity were unremarkable, and his mood and affect were appropriate in nature, range, and intensity to the situation and to the topic of conversation. The examiner detailed that the Veteran became visibly emotional at times, and that he denied current suicidal or homicidal ideation, intent, or plan. The examiner found that the Veteran's PTSD symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, irritable or angry mood, loss of interest or pleasure in activities, appetite disturbance, fatigue or loss of energy, difficulty thinking, concentrating, or making decisions, and feelings of low self-worth or guilt. The examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The examiner remarked that the Veteran's results indicated that he was experiencing significant impairments in a number of domains, including occupational functioning, detailing: As he is no longer working, his occupational functioning is inferred from his past work history, from his current social functioning, and from the nature and severity of his current symptomatology. He has not held paid employment since 2005, when he quit work due to physical health problems. He has reported no history of employment difficulties related to his mental health conditions, although he noted that he typically worked in settings that had minimal demands for interaction with other people. He reported current difficulties with depressed and anxious mood; irritability and anger; fatigue; loss of interest in activities; diminished motivation; problems with attention, concentration, and memory; intrusive thoughts and memories; hypervigilance; and social withdrawal and avoidance that would likely limit his ability to secure and maintain gainful employment at this time. The Veteran retired 13 years ago due to physical health problems that made it dangerous for him to continue pursuing his profession of more than 30 years. Due to the mental health problems noted above, he would likely experience substantial challenges in adjusting successfully to a different work environment due to reduced reliability and productivity in fulfilling job responsibilities, as well as to difficulty establishing and maintaining effective work relationships. The examiner concluded that the Veteran's PTSD and MDD were of such severity that his disabilities precluded him from maintaining gainful employment. The Veteran obtained his records from the Little Rock Vet Center and associated them with his claims file in March 2023. See March 2023 Medical Treatment Records-Non-Government Facility. A thorough review of the records from January 2022 to March 2023 reveals the Veteran's reports of intrusive thoughts, nightmares, hypervigilance, impaired memory, anger, irritability, social withdrawal and isolation, and sleep disturbances. Careful analysis of the individual and group encounters from April 2010 to January 2018 shows that the Veteran's behavior, thought processes, and participation in group and individual therapy was consistently noted as logical, appropriate, and coherent and do not contain any findings or reports of suicidal or homicidal ideation or thoughts, gross impairment in thought processes or communication; persistent delusions or hallucinations, grossly inappropriate behavior, that the Veteran was a persistent danger of hurting himself or others, the intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time and place; and memory loss for names of close relatives, own occupation, or own name. In support of his claim, the Veteran submitted a May 2023 report from a private psychiatrist. See May 2023 Private Psychiatric Report. During the interview, the Veteran reported that he had intrusive memories and flashbacks triggered by sounds and smells, he had multiple nightmares every night, and he felt nervous and experienced physical sensations of panic. The Veteran further detailed working long hours to avoid his intrusive thoughts in his previous employment and that he avoided crowds, stores, noise, and other people since his service. The Veteran detailed that he had experienced suicidal ideation and low self-worth, that he lost interest in outdoor activities and did not maintain interests outside of his work as a plumber. The Veteran stated that he felt distant and cut off from other people, that he was irritable and had violent outbursts at home, that he sat in the corner to be on guard, and was easily startled, especially by planes. The Veteran reported that he was easily distracted, had poor memory and attention, frequently forgot names, and only slept two to three hours per night. The psychiatrist found that the Veteran experienced recurrent, involuntary and intrusive distressing memories of the PTSD-related traumatic events including recurrent distressing dreams in which the content and or affect of the dream were related to the PTSD-related traumatic events, dissociative reactions (flashbacks) in which the Veteran felt as if the PTSD-related traumatic events were recurring, an intense or prolonged psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the PTSD-related traumatic events, and marked physiological reactions to internal or external cues that symbolized or resembled an aspect of the PTSD-related traumatic events. The psychiatrist further found that the Veteran engaged in persistent avoidance of stimuli associated with the PTSD-related traumatic events, including avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the PTSD-related traumatic events, and avoidance or efforts to avoid external reminders that aroused distressing memories, thoughts, or feelings about or closely associated with the PTSD-related traumatic events. The psychiatrist found that the Veteran experienced negative alterations in cognitions or mood associated with the PTSD-related traumatic events including a persistent negative emotional state, a markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, and a persistent inability to experience positive emotions. The psychiatrist further found that the Veteran experienced marked alterations in arousal and reactivity associated with the PTSD-related traumatic events including irritable behavior and angry outbursts typically expressed as verbal or physical aggression, hypervigilance, an exaggerated startle response, problems with concentration, and sleep disturbances. The psychiatrist found that the Veterans symptoms had lasted more than one month, noting that the Veteran "had suffered for decades," that his PTSD caused clinically significant distress or impairment in social, occupational, or other important areas of functioning and indicated that his symptoms created social isolation, conflict with his family, and limited his vocation. The psychiatrist expounded upon the Veteran's MDD, noting that it was not a competing diagnosis but was secondary to his PTSD, and was manifest by symptoms of depressed mood most of the day, nearly every day, a markedly diminished interest in pleasure in all, or almost all activities, insomnia, feelings of worthlessness, a diminished ability to think or concentrate, and recurrent suicidal ideation. After a review of the Veteran's claims file, his medical treatment records, and an interview with the Veteran, the psychiatrist opined that the Veteran's PTSD symptoms, on their own, significantly impaired his ability to work and that he was totally disabled, socially and occupationally, due to his PTSD symptoms since, at minimum, 2009. In support of his claim, the Veteran submitted a SSA earnings record which shows that he has not earned any income since 2005. See May 2024 SSA/SSI Letter. The Veteran also submitted a May 2024 VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, and reported therein that his PTSD had prevented him from securing or following a substantially gainful occupation and that he left his employment because of his disability. A thorough analysis of the Veteran's VA treatment records during the period on appeal reveal his reports of PTSD-related headaches and nightmares for which he previously took prescription medication, reports of depression, anxiety, issues with anger, irritability, marital strife, nightmares, insomnia, disturbances in motivation and mood, hypervigilance, sleep disturbances, avoidance behaviors, intrusive thoughts, and flashbacks. See May 2024 CAPRI. Careful review of encounters with medical treatment providers during the period on appeal shows that the Veteran's behavior, thought processes, and participation in individual therapy was consistently noted as logical, appropriate, and coherent and do not contain any findings or reports of suicidal or homicidal ideation or thoughts, gross impairment in thought processes or communication; persistent delusions or hallucinations, grossly inappropriate behavior, that the Veteran was a persistent danger of hurting himself or others, the intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time and place, and memory loss for names of close relatives, own occupation, or own name. The Veteran underwent a fourth VA examination in July 2024. See July 2024 Review PTSD DBQ. Therein, the examiner diagnosed the Veteran with PTSD; the examiner did not note any additional psychiatric diagnoses. The Veteran stated that he currently resided with his wife, that his son was about to move into a home on adjoining property, and his adult grandson lives nearby. The Veteran reported high marital satisfaction as well as regular positive interactions with his son, grandson, and siblings. The Veteran detailed he occasionally spoke on the phone with a buddy who was also a Vietnam veteran, and that he occasionally hiked with his son or helped his son or grandson with home projects. The Veteran stated that he attended church regularly, that his spiritual beliefs were key to his ongoing survival, and that he had regular contact with people who attend church with him. The Veteran detailed his ongoing participation in group and individual PTSD therapy sessions and that he no longer took prescription medication for his PTSD due to the sedative side effects. The examiner found that the Veteran experienced intrusion symptoms associated with the PTSD-related traumatic events, including recurrent, involuntary, and intrusive distressing memories of the PTSD-related traumatic events, recurrent distressing dreams in which the content and/or effect of the dream are related to the PTSD-related traumatic events, intense or prolonged psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the PTSD-related traumatic events, and marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the PTSD-related traumatic events. The examiner indicated that the Veteran engaged in persistent avoidance of stimuli associated with the PTSD-related traumatic events evidenced by his avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the PTSD-related traumatic events and avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that aroused distressing memories, thoughts, or feelings about or closely associated with the PTSD-related traumatic events. The examiner further found that the Veteran experienced negative alterations in cognitions and mood associated with the PTSD-related traumatic events as evidenced by his persistent, distorted cognitions about the cause or consequences of the PTSD-related traumatic events that led to the Veteran to blame himself or others and a markedly diminished interest or participation in significant activities. The examiner further found that the Veteran had marked alterations in arousal and reactivity associated with the PTSD-related traumatic events as evidenced by his hypervigilance, exaggerated startle response, and problems with concentration. The examiner noted the Veteran's reports of having nightmares almost every night and that he remained sensitive to environmental cues that resembled experiences in Vietnam, including the smell of diesel fuel or swampy water. The examiner remarked that the Veteran's intrusive recollections provoked physiological arousal and that he did not report any difficulties relating to his family members but he was uncomfortable in groups of people (e.g., crowded stores) due to his hypervigilance/heightened arousal response. The examiner noted that the Veteran reported some concentration issues and ongoing sleep difficulties which were partially due to nightmares occurring almost nightly, but that his concentration issues were mild and did not substantially interfere with his ability to complete tasks, although his efficiency and accuracy were sometimes mildly undermined. Regarding mood functioning, the Veteran stated that he felt depressed occasionally but not consistently. The examiner noted that the Veteran did not report substantial symptoms of a mood disorder that would justify a separate diagnosis. The examiner concluded that the Veteran's PTSD symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships caused clinically significant distress or impairment in social, occupational, or other important areas of functioning and had lasted more than one month. The examiner concluded that his PTSD disability resulted in occupational and social impairment with reduced reliability and productivity. The examiner found that the Veteran's PTSD disability would impact his employability and indicated that the Veteran would have difficulty maintaining concentration and focus on work over a period of time or he would tend to skip from one task to another without completing the prior task. In support of his claim for an increased rating, the Veteran submitted a lay statement from his son in February 2025. See February 2025 Buddy/Lay Statement. Therein, the Veteran's son stated: Over the years I have noticed a steady decline in my father's cognitive abilities related to his PTSD. Such examples include his inability to sleep at night for more than one to two hours continuously. I ask him what it is that keeps him up at night and he states that he has nightmares. He refuses to talk to me about these bad dreams. All this only leads to a disruptive sleep pattern. The lack of sleep and overwhelming feeling of exhaustion only contributes to other multiple complications that affect his overall health and well-being. His lack of appetite being one of them. He reports that nothing sounds good to him and he is obviously too exhausted to attempt to cook or prepare a meal. Other examples include his communication skills and irritability with himself and others. He can get very argumentative and will sometimes avoid talking to his family members and friends. I frequently observe his difficulty in trying to carry on a normal conversation, forgetting people's names or understanding a conversation that someone may be having with him. He often requires frequent reminders to groom his appearance, lock the doors, take his medication, and any other task he is involved with. All of these examples that I have provided; Difficulty sleeping, exhaustion, poor appetite, communication barriers, and irritability, have steadily worsened over the past few years period he is especially irritated when he is around crowds of people and so he usually likes to be left alone. These experiences have only caused my father to have increased frustration with himself and others, leading [sic] him with the lack of interest in wanting exposure or visiting with others in a public setting. When discussing "sedentary work" in its analysis below, the Board intends the common meaning of a non-physical job, primarily involving sitting and usually performed in an indoor, office-type environment. Withers, 30 Vet. App. at 147-48. When utilizing the following subjective adjectives, the Board intends the common meaning of the word or hyphenated word in the following definitions from Merriam-Webster's Dictionary Online: "sedentary," defined as "doing or requiring much sitting" or "not physically active;" "semi-sedentary" defined as "partially or somewhat sedentary;" "mild," defined as "gentle in nature of behavior;" "not being or involving what is extreme;" "moderate," defined as "not violent, severe, or intense" or "limited in scope or effect;" and "severe," defined as "causing discomfort or hardship;" "very painful or harmful;" "of a great degree;" and "marked," defined as "having a distinctive or emphasized character." "Moderately severe," therefore, can be defined as between "not violent, severe, or intense" or "limited in scope or effect" and "causing discomfort or hardship," "very painful or harmful," "of a great degree." The Board further notes that it will resolve reasonable doubt in favor of the Veteran regarding the concurrent symptoms arising from his non-service connected MDD during the period on appeal. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam) (explaining that VA must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant's service-connected disability). The Board has carefully considered the Veteran's lay statements, as well as the lay statements from his wife and son, his relevant VAMC treatment records, the May 2023 private psychiatric report and medical opinion, and the VA examinations afforded to the Veteran in April 2013, April 2018, July 2024. After engaging in a thorough and holistic analysis assessing the severity, frequency and duration of the signs and symptoms of the Veteran's PTSD disability, recognizing that the symptoms listed in the rating criteria are non-exhaustive examples and when looking at the effects determining the impairment level, the Board finds that the Veteran's disability picture most closely approximates a 70 percent rating for the entire the period on appeal. See Vazquez-Claudio, 713 F.3d at 117; Bankhead, 29 Vet. App. at 22 (noting the importance of suicidal ideation in the criteria for a 70 percent rating); Mauerhan, 16 Vet. App. at 443. Put simply, there was no increase or decrease of the Veteran's PTSD during the period on appeal; it was of the same severity from June 9, 2009, forward. In so finding, the Board finds the Veteran's lay statements, as well as the lay statements from his wife and son, his relevant VA treatment records, the May 2023 private psychiatric report and medical opinion, and the VA examination afforded to the Veteran in April 2018 to be the most probative evidence that the Veteran's disability more closely approximates occupational and social impairment with deficiencies in most areas consistent with a 70 percent disability rating. Caluza, 7 Vet. App. 511-12. In denying a disability rating in excess of 70 percent for the entire period on appeal, the Board has considered the lay statements of the Veteran's son and the Veteran's outstanding group therapy records pursuant to the October 2022 JMPR. While the Veteran's son is competent to report what he has observed, a disability that justifies a 100 percent rating is so severely disabling that some of the examples of symptoms include 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 and place; and memory loss for names of close relatives, own occupation, or own name. Layno, 6 Vet. App. at 469. The Board finds that the other medical and lay evidence of record persuasively weighs against a finding that the Veteran has exhibited such symptoms or that his symptoms resulted in impairment warranting a 100 percent rating at any point during the period on appeal. Lynch, 21 F.4th at 781. As the evidence of record persuasively weighs in favor of a 70 percent rating for the Veteran's PTSD disability for the entire period on appeal, there is no doubt to resolve, and a rating of 70 percent is granted from June 9, 2009, to April 17, 2018, and from April 18, 2018, forward, a rating in excess of 70 percent is denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch, 21 F.4th at 781. Consistent with the above finding that the Veteran's PTSD resulted in occupational impairment is the Board's grant of a TDIU rating based solely on his PTSD from June 9, 2009. The Veteran has an eighth grade education and his vocational training and occupational experience is exclusively in plumbing. The Veteran's chronic fatigue arising from his sleep disturbances and nightmares would affect the Veteran's physical endurance and ability to sit, stand, or walk for periods of time. His memory problems, issues with concentration, and irritability would have a marked effect on his ability to adapt to change, handle workplace stress, interact and get along with coworkers, and establish and maintain effective work relationships. The Veteran's chronic sleep impairment would impair his ability to concentrate and complete occupational tasks. Although the Veteran was not employed, marginally or otherwise, during the period on appeal, the Board finds that the Veteran's mental and physical occupational impairment caused by the Veteran's service-connected PTSD was marked and of such severity as to totally preclude gainful employment. Ray, 31 Vet. App. at 73; Cantrell v. Shulkin, 28 Vet. App. 382 (2017); Labruzza v. McDonough, 37 Vet. App. 111 (2024). In making this finding, the Board finds the lay statements of the Veteran are corroborated by the April 2018 VA examination report and May 2023 private psychiatric opinion and in this regard, finds this evidence to be highly probative and consistent with the Board's finding that a TDIU rating is merited from June 9, 2009. Caluza, 7 Vet. App. 511-12. To this end, the Board acknowledges that there is evidence of mental and physical occupational impairment from the Veteran's service-connected bilateral upper and lower peripheral neuropathy disabilities during the period on appeal and his reports that he retired and was in receipt of SSA disability for same. However, the question before the Board is whether the Veteran's PTSD, on its own, precluded his performance of the physical and mental acts required by employment and was of sufficient severity to produce unemployability. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993): Bradley, 22 Vet. App. at 293; Buie, 24 Vet. App. at 250. When resolving reasonable doubt in favor of the Veteran, the answers to those questions result in a grant of a TDIU rating based solely on his PTSD for the entire period on appeal. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (reasonable doubt to be resolved in Veteran's favor); Lynch, 21 F.4th at 781. Lastly, the Board turns to address the Veteran's entitlement to SMC(s). SMC provided by 38 U.S.C. § 1114(s) is payable when a Veteran has a service-connected disability rated as 100 percent and has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. See 38 U.S.C. § 1114(s)(1); see also 38 C.F.R. § 3.350(i)(1). SMC under 38 U.S.C. § 1114(s) is also payable when a Veteran has a service-connected disability rated as 100 percent and is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s)(2) see also 38 C.F.R. § 3.350(i)(2). This requirement is met when a Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. Id. As is the case here, a TDIU rating may satisfy the first statutory requirement that the Veteran has a 100 percent rating for the award of SMC if the Veteran's unemployability is based on a single disability and as discussed above, the Board has found that the Veteran's PTSD was of such severity as to totally preclude employment during the entire period on appeal. Bradley, 22 Vet. App. at 293; Buie, 24 Vet. App. at 250. He is also in receipt of a combined 100 percent disability rating for his service-connected bilateral upper and lower peripheral neuropathy disabilities which are separate and distinct from his PTSD and involving different anatomical segments or bodily systems. See 38 U.S.C. § 1114(s)(1). SMC(s) is thus granted from June 9, 2009, forward. DUSTIN L. WARE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Buntin, M.E. 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.