Citation Nr: 22061187 Decision Date: 11/01/22 Archive Date: 11/01/22 DOCKET NO. 15-10 668 DATE: November 1, 2022 ORDER Entitlement to a 50 percent rating, but no higher, prior to May 12, 2015, for service-connected posttraumatic stress disorder (PTSD) is granted. Entitlement to a rating in excess of 50 percent from May 12, 2015 to October 28, 2019, for service-connected PTSD is denied. Entitlement to a 100 percent rating from October 28, 2019 to January 20, 2022 for service-connected PTSD is granted. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to November 18, 2017 is denied. FINDINGS OF FACT 1. The evidence of record indicates that prior to May 12, 2015, it is ascertainable that the Veteran's PTSD symptoms manifested in symptoms such as anxiety, panic attacks, nightmares, and some memory loss, to include forgetting tasks and directions, and emotional detachment. 2. The evidence of record indicates that from May 12, 2015 to October 28, 2019, it is ascertainable that the Veteran's PTSD symptoms manifested in symptoms such as anxiety, panic attacks, nightmares, some memory loss, to include forgetting tasks and directions, emotional detachment, and difficulty establishing and maintaining effective work and social relationships. 3. The evidence of record indicates that from October 28, 2019, it is ascertainable that the Veteran's PTSD manifested in symptoms such as passive thoughts of death, and intermittent inability to perform activities of daily living, causing total occupational and social impairment. 4. The evidence of record does not show that the Veteran was unable to obtain or maintain gainful employment due to his service-connected knee, back, or PTSD conditions, individually or in aggregate, prior to November 18, 2017. CONCLUSIONS OF LAW 1. For the period prior to May 12, 2015, the criteria for an initial rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9411. 2. For the period of May 12, 2015 to October 28, 2019, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9411. 3. For the period of October 28, 2019 to January 20, 2022, the criteria for a rating of 100 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9411. 4. The criteria for TDIU prior to November 18, 2017 have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the United States Army from July 1989 to January 1996. The Veteran's awards and decorations include the Army Achievement Medal, Valorous Unit Award, Army Good Conduct Medal, Southwest Asia Service Medal with 3 Bronze Service Stars, and the Kuwait Liberation Medal. In March 2019, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing. A copy of the transcript has been associated with the claims file. In March 2019, the Board remanded the appeal for further development. In May 2020, the Board issued a decision which denied the claims on appeal. The Veteran filed a timely appeal to the Court of Appeals for Veterans' Claims (Court). In a July 2021 Joint Motion for Remand, the parties agreed to remand the appeal to the Board for further development. In December 2021, the Board remanded the appeal for further development. 1. A rating in excess of 30 percent prior to May 12, 2015, in excess of 50 percent from May 12, 2015 to October 28, 2019, and in excess of 70 percent from October 28, 2019 to January 20, 2022 for service-connected PTSD The Veteran contends that his PTSD is such that higher ratings are warranted. Throughout the periods on appeal, the Veteran was rated under 38 C.F.R. § 4.125 Diagnostic Code 9411. Under Diagnostic Code 9411, which is governed by a General Rating Formula for Mental Disorders (General Rating Formula), a 30 percent 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). 38C.F.R. §4.130, Diagnostic Code (DC) 9411. A 50 percent 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; and/or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name). Id. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the General Rating Formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. At the outset, the Board notes that, during the pendency of the appeal, the Veteran was awarded a 100 percent PTSD rating, effective January 20, 2022. As the Veteran has received that maximum rating for this period, the issue of a higher rating is moot from January 20, 2022 and thereafter. Therefore, analysis will turn to prior rating stages. In June 2012, the Veteran underwent a brief VA mental health evaluation. The Veteran reported that he continued to work as a press operator and hoped to start attending college to study nursing in the fall. He indicated that he had attended his daughter's high school graduation and that she would be moving closer to him in Birmingham to start her freshman year at college. The Veteran expressed anxiety as the time came closer for his daughter to relocate near him, as he felt guilty for not participating in her life as she grew up separated from distance and felt a sense of urgency to make up for the lost time. The Veteran went on to note that that he took medication to sleep for approximately five hours at night. The Veteran stated that he is not aware of actual nightmares, but he does frequently awaken in a cold sweat with panicky feelings. The examiner noted that the Veteran has significantly reduced alcohol intake to zero consumption only on weekends when socializing with friends. The psychologist found that the Veteran's mood was dysphoric and anxious, and his affect was congruent with his mood. She also found that the Veteran had some mild intermittent stuttering, but that his thought process was logical and linear. The Veteran verbalized subjective complaints of memory loss for recent and remote events. The psychologist found that the Veteran's current suicide and aggressive risks were low, as he did not appear to be at imminent risk to harm himself or another person. The psychologist also found that the Veteran was appropriately groomed and dressed, and was polite and cooperative. He was alert and oriented and had normal attention, concentration, and judgment, as well as fair insight. The Veteran underwent a VA examination in July 2012. Therein, the examiner found that the Veteran's occupational and social impairment was best summarized as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. Regarding social functioning, the Veteran reported that he currently lived with his mother and that their relationship was at times strained. He stated that he had frequent contact with his stepfather, occasional contact with his biological father, regular contact with two siblings that lived close by, and less contact with siblings that lived outside the state. The Veteran reported being separated from his ex-wife since 1996. He indicated that he was in the process of rebuilding the relationship with his college-age daughter and that it was hard, as they would both feel slighted. Regarding occupational functioning, the Veteran reported that he had been employed as a press operator since January 2012. He indicated that he planned to leave the job mostly because of his back, but also stated that "[m]anagement sucks." He denied having ever been fired from a job or having problems interacting with co-workers. The Veteran reported that outside of work, he destressed and tried to meditate, exercise, and read about philosophy and African history. He occasionally watched news on the television and would rent a movie on the weekend. He avoided war movies. The Veteran also reported that he was at times bothered by intrusive thoughts and images of dead soldiers. He reported sleep disturbance and night sweats since returning from deployment, as well as occasional disturbing dreams. He also described feeling detachment and an overriding feeling that he was different from other people since he returned from Iraq; as such, the Veteran reported limiting his interactions with others. The Veteran reported continued hypervigilance in public settings, resulting in him engaging in few activities outside of home and work. Examination revealed that the Veteran was cleanly dressed and adequately groomed. Speech was unremarkable, and thought processes were logical and goal-directed. Speed of thinking and responding was normal. There was no evidence of mental content symptomatology, perceptual disturbance or gross cognitive confusion. Insight and judgment were fair to good. He was fully oriented to person, place, and time. He reported that his attention and concentration were fairly decent, but indicated he had some problems with remote memory. The Veteran maintained that he was easily stressed and overwhelmed at times, but denied problems with irritability and anger. He also denied suicidal ideation, excessive worry, hallucinations, and delusions. The Veteran reported that occasional flashbacks were vivid and intense and sometimes disorienting, but that he had a tight grip on reality. The examiner found that the Veteran had symptoms such as depressed mood, anxiety, suspiciousness, and chronic sleep impairment. She indicated that his PTSD symptoms were presently mild, chronic, and ongoing, and resulted in mild impairments in functioning. In a March 2013 statement in support of claim, the Veteran expressed his disagreement with the initial 30 percent rating for his PTSD. He reported that the RO had not considered items such as his difficulty in establishing and maintaining effective work and social relationships, disturbances of motivation and mood, impairment of short and long term memory, difficulty understanding complex commands, and flattened affect. The Veteran wrote that he suffered with the aforementioned impairments on a daily basis. The Veteran also reported that he had not been able to be in a long-term relationship for a long time. He discussed how he did not go out anymore and remained closed off in his mom's basement. The Veteran explained that crowds made him feel uneasy and vulnerable; he endured all the interacting he could handle during work. He reported that he lied to his therapist most of the time. The Veteran concluded that he was just not able to feel anything. He reported that "everything feels very distant" and he was unable to get in touch with the emotion of any event. For example, his daughter was nearly killed and he did not feel anything. In a May 2014 VA mental health evaluation, the Veteran reported that he was exhausted both emotionally and physically. The Veteran confirmed that he was continuing to suffer from symptoms of his PTSD such as impaired sleep and several nightmares per week. The Veteran also perceived that academic and work stress as well as ongoing family stressors had exacerbated his symptoms of anxiety, dysphoria, and insomnia. The Veteran did not report any thoughts of suicide or homicide. The Veteran underwent a VA mental health evaluation in August 2014. The Veteran reported that his PTSD symptoms had worsened. Specifically, he reported that he experienced abrupt worsening of his depressive symptomatology with accompanying symptoms of anergia, amotivation, and anhedonia. At the evaluation, the psychologist noted that the Veteran's mood was anxious and dysphoric, his affect was congruent with his mood, his speech was fluent and at a regular pace, his thought process was logical and linear, his attention was within normal limits, and his memory was intact both recent and remote. The psychologist found that the Veteran's current suicide risk was low as the Veteran did not appear to be at imminent risk to harm himself. Similarly, the psychologist found that the Veteran's current aggressive risk was low as the Veteran did not appear to be at imminent risk of harming another person. In a buddy statement from September 2014, the Veteran's mother provided information regarding the Veteran's mental condition. She provided that when the Veteran returned from service, he was not the same son she sent away. She reported that his temperament was different, and that he was very angry, easily frustrated, and withdrawn. She also stated that the Veteran was not able to sleep well; when the Veteran was awake, he was up just walking around the house talking to himself, occasionally until early morning hours. The Veteran's mother described that the Veteran still jumped to his feet and started marching before he became aware of his surroundings. He would have dreams, and she could hear him calling out or talking to fellow soldiers. He would get frightened and snap at her if she came up to him suddenly, especially from behind. She stated that the Veteran did not attend many family functions and when he did attend, their conversations were guarded. The unexpected sound of a telephone, microwave, or alarm clock startled him so badly that he would jump to his feet and take a combat stand. She also commented on the Veteran's lack of concentration. She reported that there were times when the Veteran's concentration was so bad that he did not remember how to get to familiar places. For example, he had called with his location and asked how to get to the VA from where he was. On another occasion, he was driving to his sister's house, a place he was familiar with, and lost his way and ended up back home. At times, the Veteran would start something, forget what he was doing, and begin something else. He would sometimes offer to go to the store and then forget an item. The Veteran also submitted a lay statement in September 2014. Therein, the Veteran expressed his discontent with his previous VA examinations. He discussed how everything was tiring and how every task seemed to take a significant amount of energy. He reported that things had gotten so bad that there was an entire week he could not leave the house because it seemed like he was being bombarded, that every task seemed to weigh as much as the world, and he was being crushed beneath the weight. He reported that his memory and concentration were failing him in school. The Veteran also reported that his memory was extremely bad; he was not able to remember people or events that he should. He described that his memories were reduced to bits and pieces. He stated that he still suffered from insomnia, nightmare, and night sweats. In October 2014, the Veteran was afforded a VA examination. The examiner opined that the Veteran's level of occupational and social impairment could be summarized as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, though generally functioning satisfactorily with normal routine behavior, self-care, and conversation. The Veteran reported that he lived in a home with his mother. He also reported that he last dated four to five years ago and was not in a relationship at the time. The Veteran discussed his attenuated relationship with his 20 year old daughter, stating that he was open to having a relationship with her despite the fact they currently have little contact. The Veteran reported having two close friends that lived in other states, but stated they had not spoken in a long time. He otherwise reported having no friends or social relationships in his area. He also reported that he enjoyed monthly events at the downtown library. He also volunteered at Care First where he did his clinicals in school. He further indicated that he watched movies and news on TV and did upkeep around the house. The Veteran reported working part-time on the weekends doing security in a gated community. He worked alone and had few problems at work. The examiner found that the Veteran exhibited symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss, such as forgetting names, directions or recent events. The Veteran was appropriately groomed and dressed. He was cooperative and mildly irritable during the examination. He denied any mania, obsessive-compulsive symptoms, panic attacks, hallucinations, and suicidal and homicidal ideation. Speech was spontaneous, fluent, and normal in rate and rhythm. His mood was noted to be dysthymic, and affect was mildly restricted and anxious. The Veteran reported being "numbed out" and not having an emotional attachment to anything. He had difficulty with onset and maintenance of sleep and sometimes woke from dreams. Thought process was logical and organized, and thought content was relevant and non-psychotic. He had mildly impaired attention, concentration, and recent memory. Judgment and insight were fair. The Veteran also participated in an Individual Placement and Support Towards Advancing Recovery (VIP STAR) program in October 2014. In a corresponding research note, the specialist determined that the Veteran's symptoms were globally moderate and made it difficult for him to function socially, occupationally, interpersonally, and emotionally. The Veteran did not show signs of suicidal or homicidal ideation. In a May 2015 mental health note, the physician determined the Veteran had constricted affect and poor insight and judgment. In a July 2016 note, the private physician found that the Veteran had neither suicidal ideation nor homicidal ideation. The Veteran exhibited a euthymic mood with no signs of depression or manic process. He presented as anxious, and well-groomed and dressed. The Veteran denied hallucinations and delusions. There was no apparent thought disorder, and thinking was generally logical. Thought content was appropriate, and insight and judgment appeared intact. Speech was decreased in rate and spontaneity. In an August 2016 mental health note, the Veteran exhibited symptoms of worsening anxiety, including halting and stuttering-type speech. He reported that his mother moved back to her previous home and he was now residing alone, which brought him feelings of relief. The Veteran reported that his daughter continued to avoid speaking with him, with the exception of contacting the Veteran to pressure him to allow his ex-wife and daughter to rent the home that the Veteran resides in if the Veteran decided to relocate to a smaller residence. The physician found that the Veteran was appropriately groomed, casually attired, and cooperative. The Veteran's memory was noted to be intact in recent and remote. The Veteran reported feeling very distressed by chronic sleep disturbance. He also expressed concern that fatigue and problems with attention and short-term memory would lead him to make critical errors at work, although he reported that this had not happened, as his supervisor had voiced no dissatisfaction with the quality of his work performance. He denied suicidal and homicidal ideation. In an October 2016 mental health note, the Veteran reported continued prominent decreased concentration and short-term memory. He reported that this problem affected his daily life, especially work performance. He denied any suicidal ideation. The Veteran also reported stressful interactions with his mother and daughter, and feeling that his daughter's mother was overly dependent on the Veteran to call and ventilate problems with. The Veteran reported being concerned about his strong preference to avoid phone conversations with relatives and his daughter's mother but stated that he was exhausted and did not have the energy to listen. He also reported being ambivalent about having a serious romantic relationship. The Veteran reported that he felt too tired to offer much to another person in terms of attention and time. Examination revealed that the Veteran was appropriately groomed and casually attired; he was polite and cooperative and ambulated independently. Despite reports of concentration and memory problems, the physician noted that the Veteran's memory was intact both recent and remote. The Veteran was afforded a VA examination in May 2017. Therein, the examiner determined the Veteran's impairment was best described as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran reported that he and his daughter had a strained relationship but that they had begun getting along a lot better recently. She had been living with him for the past four months. He discussed keeping in touch with one of his brothers and being on good terms with his sisters. The Veteran also reported that he loved his mother despite only being able to handle her in doses. He indicated that he had one friend in Colorado that he talked to from time to time. The Veteran reported having difficulty with focus and attention. He noted he recently caught himself making errors at work and indicated that his supervisor had brought several recent errors to his attention that he was unaware of having made. He stated that he had trouble with both short-term and long-term memory, stating that while he heard requests, he had trouble properly executing them and instead would do something different. The examiner found that the Veteran exhibited symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. The examiner also reported that the Veteran was casually dressed with adequate grooming and hygiene, as well as fully oriented. Speech was clear and coherent, but often halting, as the Veteran seemed to have a hard time expressing himself. There were no signs of distorted thoughts or perceptions. Affect was constricted, but the Veteran reported that lately his mood had been more dysphoric than euthymic. He stated that he felt stressed about his health, poor focus and concentration, and job stability in light of his memory and focus problems. He did not like being in crowds and avoided watching war movies. He denied suicidal and homicidal ideation. Attention was within normal limits. Judgment was average, and insight and impulse control were fair. In a December 2017 mental health note, the Veteran reported a persistence of his PTSD and worsening symptoms since he was previously seen. Specifically, the Veteran reported no longer being employed after he missed a meeting and subsequently had disciplinary action taken against him. He reported that anger and temper symptoms were triggered after the disciplinary action was taken. The Veteran denied any suicidal or homicidal ideation. He continued to describe himself as easily distracted and continued to complain of memory problems that contributed to his anxiety and depressive symptoms. In a January 2019 VA medical record, the Veteran reported to a walk-in mental health clinic. The Veteran reported that he requested an unscheduled walk-in treatment due to having to cancel his scheduled appointments in December 2018 due to involvement in a moving vehicle accident and lack of transportation. The Veteran noted that he was not injured during that accident, but it did result in having to borrow money from a relative. The Veteran reported unemployment starting in November 2017, though he had recently found a part-time job as a security guard while the Veteran continued to look for employment in his previous field. The Veteran stated that he remained unemployed due to chronic PTSD symptoms as well as multiple medical issues including headaches, chronic pain symptoms and unresolved ongoing short-term memory complaints and attentional difficulties which the Veteran reports had their onset following a neurological event which brought the Veteran to a VA emergency room several years ago with symptoms of altered mental state. The examiner noted that neurological work-up, performed at the time, did not identify any specific etiology but, the Veteran reports that attention/concentration and short-term memory deficits persist, unresolved, since the altered mental state event several years ago. Veteran reported that although he does not feel cognitively able to work full-time, he has started looking for part-time jobs due to worsening financial stressors, long history of unemployment, and now owing money to his relative due to the December 2018 moving vehicle accident. The Veteran went on to report that he has remained compliant with taking prescribed psychotropic medications. The Veteran described PTSD symptoms (combat-induced) as persisting, and unchanged in symptom severity and frequency since previous primary care treatment in September 2018. The Veteran stated that PTSD symptoms remain severe and include symptoms of sleep disturbance with frequent PTSD nightmares of prior combat-related trauma experiences, hypervigilance, intrusive, distressing recollections of prior combat trauma experiences, distrust of others, persistent feelings of impending doom, and heightened hypervigilance and physiological hyperarousal in crowded venues. The examiner noted that the Veteran continues to prefer to spend time alone, trying to minimize time spent with others. The Veteran described recent Thanksgiving and Christmas/New Year's holidays as stressful due to his mother requesting him to attend holiday meals with extended family members. The Veteran described these events as highly stressful. The Veteran reported that his daughter remains estranged from him, having remained angry with the Veteran after he declined to buy a replacement car for his daughter after she totaled the car which the Veteran had purchased for her at the start of her college career. The Veteran also stated that he does not get along well with her mother and her boyfriend. The Veteran reported that he left a previous part-time job as a security officer at a busy truck stop due to several incidents with disruptive customers triggering distressing flashbacks for him pertaining to his history of prior combat-related trauma events. The Veteran stated that working at this very busy and dangerous truck stop/convenience store was dangerous, and he decided that he was unable to continue working this type of job due to the frequency of flashbacks he was experiencing while on the job. The Veteran reported that he is searching for part-time employment, as he is experiencing dire financial stressors, but fears that he may not be able to maintain gainful employment due to problems caused by his chronic PTSD and attention/concentration and problems involving short-term memory, especially when working in a stressful and/or fast-paced environment. The Veteran noted that headaches had previously decreased in frequency but since Thanksgiving, his headaches resumed prior frequency. The Veteran reports that he has reduced alcohol intake. He noted prior tobacco use that discontinued in 2003. The Veteran reported continued sleep disturbance with complaint of fatigue much of the time. The Veteran also continued to describe himself as easily distracted and having problems with memory disturbance, which exacerbated his anxiety and depression when he was previously employed. The examiner observed that the Veteran was appropriately groomed and casually attired. The examiner noted that he was polite and cooperative with the therapist during the session. The examiner stated that the Veteran ambulated independently. The examiner noted that the Veteran was seen alone today. The examiner stated that the Veteran did not exhibit (and denied) symptoms of acute psychiatric disturbance. The examiner noted, however, that the Veteran's mood appeared anxious and dysphoric. The examiner stated that the Veteran had good eye contact and unremarkable psychomotor activity with mild psycho motor slowing with complaint of chronic pain symptoms. The examiner stated that the Veteran's speech is fluent, regular rate, and spontaneous, and his thought process is logical and linear. The examiner observed that the Veteran's verbal and oral comprehension and attention and concentration were within normal limits. The examiner stated that the Veteran's recent and remote memory was intact. The examiner endorsed that the Veteran's associations were logical and thought content was relevant. The examiner noted that the Veteran denied prior suicidal, homicidal, violent, or self-injurious behaviors. The examiner reported that the progress of the Veteran's diagnosis of PTSD is stable. The Veteran testified at a Board hearing in March 2019. Therein, the Veteran stated that he lost his job due to his PTSD, that he was not sleeping, and that he could not interact with people in the community. The Veteran reported being unable to leave his home for up to a week at a time because of depression. The Veteran was unable to remember most of his life, citing depression as impacting his memory. The Veteran stated that due to his memory issues, he was putting patient safety in jeopardy at his previous job. The Veteran noted that he had chronic insomnia that is not alleviated by sleeping aids. The Veteran reported difficulty dealing with people as he has low tolerance and patience. The Veteran also reported flashbacks to service and disturbing images he was exposed to. The Veteran's productivity was reportedly markedly decreased, and he described struggling to have sustained employment. The Veteran reported being unemployed for nearly a year and a half. In May 2019, the Veteran underwent a VA examination. The examiner determined that the Veteran's impairment was best described as occupational and social impairment with reduced reliability and productivity. The Veteran reported that he had sporadic contact with his ex-wife and no current romantic relationship. He had no contact with his daughter and lived alone. He maintained contact with his mother and siblings and had a couple of friends from the military. Otherwise, he did not socialize. The examiner found that the Veteran had symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and disturbance of motivation and mood. The Veteran presented as casually dressed to the examination, with good grooming and hygiene, and was oriented in three spheres. Speech was noted to be halting and indirect. The Veteran frequently noted difficulty with memory. He described his mood as annoyed, depressed, and tired. Affect was neutral. He expressed enhanced startle to his phone ringtone. The Veteran had no suicidal or homicidal ideation. He reported nightmares from time to time. He maintained anger and irritability problems and stated that he tried to suppress his emotions and walk outside. He did not like crowds and had difficulty with closed-in spaces. He had no hallucinations. In October 2019, the Veteran underwent a VA examination. The examiner determined that the Veteran's level of impairment was best described as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and or mood. The Veteran reported that he currently lived by himself and did not speak to his daughter. He checked in with his mother at least once a week and had three friends with whom he served in the military. The Veteran reported that he was easily angered and short tempered. He also stated that his memory had declined, and he could not think clearly. The Veteran also reported being depressed and staying in bed. He stated that he felt worthless, had low energy, stayed indoors, had passive thoughts of death, appetite dysregulation, poor concentration, and sleep dysregulation. He reported that performing simple tasks was difficult for him, and it took so much effort to make it through a day. The examiner found that the Veteran had the following symptoms: depressed mood, anxiety, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, mild memory loss, impairment of short and long term memory, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and intermittent inability to perform activities of daily living. In a January 2022 VA examination, the examiner noted diagnoses of PTSD and major depressive disorder. The examiner stated that diagnoses of headaches, hypertension, diabetes and chronic back and joint pain were relevant to the understanding or management of the mental health disorder. The examiner noted that the Veteran's symptoms were not possible to differentiate to attribute to individual diagnoses. The Veteran reported that he had been married since about 1993 or 1994, and he went to Korea about six months after. The Veteran stated that they had not lived together since 1994 when he was in Korea. He was unsure if he considered them together. The Veteran noted that they did currently talk, but she had other relationships while he did not. The Veteran was not currently in a relationship. The Veteran reported that he lived alone in a house. He stated that he had three close friends, but he had not talked to them in years. The Veteran also reported that he had been estranged from his daughter for the last three or four years. The Veteran stated that he had eleven siblings and was in contact with four siblings. The Veteran reported that he was currently not employed. The Veteran stated that he last worked doing part-time security. The Veteran reported that this ended around 2019 due to chronic pain and memory loss. The Veteran went on to describe that he has had almost constant anxiety for the last two years. The Veteran denied any hallucinations or delusions. He also denied obsession or compulsions. The Veteran denied violence and history of self-injurious behavior. The Veteran reported that he still had nightmares and the occasional flashback. He also stated that he was frustrated easily and found himself jumpy and paranoid. The Veteran stated that he also had insomnia, night sweats, and anxiety. He further reported decreased appetite, decreased social interest and decreased energy. The examiner endorsed symptoms of depressed mood, anxiety, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss such as forgetting names, directions, or recent events, difficulty in understanding complex commands, impaired judgement, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, inability to establish and maintain effective relationship, spatial disorientation, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner summarized the Veteran's level of occupational and social impairment as total social and occupational impairment. The examiner stated that each condition appears to contribute significantly to the Veteran's occupational and social impairment such that it is not possible to differentiate the extent attributable to each condition without resorting to speculation. After review of the record, the Board finds that prior to May 12, 2015, a 50 percent rating, but no higher, is warranted. During this period, it is ascertainable that the Veteran's PTSD symptoms manifested by anxiety, panic attacks, nightmares, some memory loss, to include forgetting tasks and directions, and emotional detachment. The evidence also indicates memory loss such as forgetting directions and tasks. The Veteran's symptoms did not approximate to a 70 percent rating prior to May 12, 2015. During this period, the evidence does not indicate that the Veteran experienced suicidal ideation, speech intermittently illogical, obscure, or irrelevant, spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), and/or inability to establish and maintain effective relationships. While the Veteran reported frequently waking in a state of panic, the evidence does not indicate that the Veteran's panic manifested in affecting the ability to function independently, appropriately, and effectively. Moreover, the Veteran's symptoms during this period did not result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Therefore, a 70 percent rating is not warranted during this period. The evidence did not indicate that the Veteran's symptoms warrant a 100 percent rating during this appeal period. While the Veteran's social functioning is impaired, it was not ascertainable that the Veteran was totally socially disabled, as he reported spending time with his daughter and having relationships with friends and other relatives, including his mother. The record also does not establish that the Veteran has gross impairment in thought processes or communication, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, or disorientation to time or place, or persistent delusions or hallucinations. Moreover, while the evidence indicates that the Veteran has experienced some memory problems, he has not had memory loss of his own name, own occupation, or close relatives. Finally, while the Veteran's PTSD had occupational impacts, he did not have total occupational impact, as he maintained employment throughout the appeal period. Therefore, a 100 percent rating during this period is not warranted. The Board finds that a 50 percent rating from May 12, 2015 to October 28, 2019 is appropriate. During this period, it is ascertainable that the Veteran's PTSD manifested in symptoms such as in depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood and difficulty in establishing and maintaining work and social relationships. During this period, it is not ascertainable that the Veteran symptoms manifested in symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, or difficulty in adapting to stressful circumstances (including work or a work-like setting). While the evidence indicates that the Veteran had a strained relationship with his daughter during this period, the evidence also indicates that the Veteran maintained some relationships, such as with his mother and friends. Therefore, during this period, it is not ascertainable that the Veteran had an inability to maintain work and social relationships. Here, a 50 percent rating, which specifically accounts for difficulty establishing and maintaining effective work and social relationships, more closely approximates to the Veteran's symptoms during this period. Thus, a 70 percent rating is not warranted during this period. The Board finds that a 100 percent rating is not warranted from May 12, 2015 to October 28, 2019. During this period, it is not ascertainable that the Veteran's symptoms manifested such that they caused total occupational impairment or intermittent inability to perform activities of daily living. Therefore, the overall frequency, severity, and duration of the Veteran's PTSD does not rise to the level of severity as needed for a 100 percent rating during this period. From October 28, 2019 to January 20, 2022, the Board finds that a 100 percent rating is warranted. During this period, it is ascertainable that the Veteran's PTSD manifested in symptoms such as passive thoughts of death, and intermittent inability to perform activities of daily living. Therefore, during this period, the Veteran's symptoms more closely approximated to a 100 percent rating. In reaching this decision, the Board has considered the Veteran's lay statements regarding the severity of his symptoms through each period. The Board notes that the Veteran is competent to report observations with regard to the severity of his symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board finds these lay statements to be credible and consistent with the ratings now assigned. To the extent he argues his symptomatology is more severe, the Veteran's statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals and documented medical treatment records are of greater probative weight than the more general lay assertions that a rating should be higher than those assigned. 2. A TDIU prior to November 18, 2017 The Veteran has asserted that he is not able to maintain gainful employment due to his service-connected PTSD. When evidence of unemployability is submitted during the course of an appeal for an assigned disability rating, a claim for entitlement to a TDIU will be considered to have been raised by the record as "part and parcel" of the underlying claim. Rice v. Shinseki, 22 Vet. App.447, 453-54(2009). In this case, there was evidence of record that the Veteran was unable to obtain or maintain substantially gainful employment due to his service-connected PTSD. The AOJ granted the Veteran's TDIU claim with an effective date of November 18, 2017. As such, the question for the Board is whether the Veteran is entitled to a TDIU prior to November 18, 2017. A Veteran may be awarded a TDIU upon a showing that she is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from her service-connected disabilities. 38 U.S.C. §1155; 38C.F.R. §§ 3.340, 3.341, 4.16. A total disability rating 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 as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For purposes of TDIU, disabilities of common etiology will be considered a single disability. Id. The existence or degree of non-service-connected disabilities or previous unemployment status will be disregarded where the percentages for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the claimant unemployable. Id. Marginal employment shall not be considered substantially gainful employment. Id.; see Cantrell v. Shulkin, 28Vet. App.382 (2017). As the TDIU claim is part and parcel of the increased rating claim for PTSD, the period on appeal is from March 8, 2012 to November 18, 2017. The Veteran's service-connected disabilities during this period included patellofemoral pain syndrome of the left knee (10 percent from January 30, 1996), patellofemoral pain syndrome of the right knee (10 percent from January 30, 1996), degenerative disc disease of the thoracic spine (10 percent from January 30, 1996), and, with the writing of this decision, PTSD (50 percent from March 8, 2012 to November 18, 2017). The schedular requirements for TDIU were met as of March 8, 2012. As such, the Board will consider whether the Veteran was unemployable due to the combined functional impact of his knees, thoracic spine, and PTSD. Turning to the evidence of record, in a primary therapist note dated March 12, 2012, the Veteran reportedly had a low energy level and discussed not feeling like doing anything. He did not identify any stressors or associate a recent down mood. He reported working quite a bit, but did not feel it was contributory to his feelings. In a May 2012 statement in support of claim, the Veteran wrote that his back and knee conditions were increasing in severity. He reported that he was experiencing a popping and instability in his knees which was reducing his range of motion in his knees and in turn causing problems with his work and social life. In a June 2012 mental health note, the Veteran reported that he continued to work as a press operator, and he hoped to attend college to study nursing. He also discussed feeling frustrated that his life seemed to revolve around work and sleep and seemed to leave insufficient time for activities which grounded the Veteran, namely meditation and exercise. The Veteran was afforded a VA examination in July 2012 for his back condition. Therein, he discussed having daily back pain that was constant and moderate in severity. He described that it was worse when lifting, carrying, bending, and during prolonged standing. The examiner concluded that the Veteran had functional loss of his thoracolumbar spine. The examiner also opined that the Veteran's thoracolumbar spine condition impacted his ability to work. The examiner elaborated that the Veteran experienced back pain after physical duties. In another July 2012 examination evaluating the Veteran's PTSD, an examiner found that the Veteran experienced occupational and social impairment due to mild or transient symptoms which decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress or, symptoms controlled by medication. The Veteran reported that he had issues having to deal with people, and that used all of his energy at work. After work, he wanted to be alone. The Veteran also discussed that after discharge from service, he worked as a welder for a couple of years, and that the job felt very physically demanding and he felt unable to keep up with the requirements. He also discussed being employed with the post office for four years but left this position due to an increase in back pain. The Veteran then worked for an airline in baggage and security and then in customer service for a period of years. Since January 2012, the Veteran reported being employed as a press operator, but planned to leave that job mostly due to his back pain but also reported that management was subpar. The Veteran also endorsed absences from work due to physical pain and just being so tired. The Veteran did not report the exact number of days of work he missed. He denied having problems interacting with his coworkers. The Veteran submitted a statement in support of his claims in March 2013. Therein he discussed how his back pain was the reason he had to leave several jobs, specifically the Army and the US Post Office in previous years. He stated he just recently had to quit the only job he could find because of the back pain. He stated that his back placed him in a very precarious position as he could not do anything remotely resembling manual labor and the skills the Army gave him did not transfer to civilian jobs. The Veteran also discussed how his PTSD caused him difficulty. He stated that he did not want to be around people, especially crowds. After a day of working, he had no energy left to handle other people. The Veteran discussed his employment in an April 2013 mental health visit. He reported that he was no longer working since some time in the year before. He described that he felt that the job was too pressuring, and they were unwilling to adjust his schedule for his college. The Veteran noted that he was attending a community college full-time to study nursing and that he remained satisfied with his educational and career goals. In an August 2013 nursing telephone care note, the Veteran called in requesting medication for his upper back pain. He reported that he had been off of work for one year at the time and continued to have pain. In November 2013, the Veteran reported increased upper back pain with his new work which was more physical. He previously did security, but he had changed to working as a press operator. In January 2014, the Veteran reported that he was working part time as a security guard which was more of a sitting job. He indicated that he was still in school studying nursing. The Veteran attended a mental health appointment in May 2014. He reported that he had transferred to a college for a medical assistant training program and he hoped to graduate in the fall. He also reported that he was working weekends as a security guard. He stated that he perceived academic and work stressors, as well as ongoing family stressors, as exacerbating his symptoms of anxiety, dysphoria, and insomnia. In another May 2014 mental health note, the Veteran discussed working 16 hour shifts every Saturday and Sunday as a security guard. In an August 2014 mental health note, the Veteran reported that he was in school and anticipated graduating with an associate's degree in the next month. Following graduation, he intended to find full-time employment as a medical assistant. He stated that he planned to work for approximately one year prior to resuming studies with a goal of obtaining a nursing degree. In September 2014 correspondence, the Veteran made lay statements regarding his circumstances and disabilities. He reported that everything was tiring, and every task seemed to take so much energy. He did not know if this was a result of his depression or PTSD, but things had gotten very bad. He discussed struggling through school and passing classes when his memory and concentration were failing him, but that he had no other choices as he could no longer perform arduous labor and his pension was not enough to live off of. He wrote that his memory was so bad that he did not remember people or events, as his memory was reduced to bits and pieces. Regarding the physical issues with his knees and back, the Veteran reported that he had increased pain, with his knees buckling more often to the point where the walls were sometimes the only thing that held him upright. He stated that his knee pain went "into overdrive" if he performed strenuous activity such that he would have to elevate his legs and ice his knees. He stated that his back pain occurred constantly instead of hurting only after performing arduous labor like it had in the past. He indicated that due to his back pain, he had to find new employment that did not exacerbate it. The Veteran wrote that finding a decent job that would afford a person a decent living was hard enough, and one that was not arduous and did not require a college degree bordered on impossible. He reported that he was currently struggling through college, but if he was unable to find suitable employment, he would flip burgers and mop floors, but such would not be enough to support his family. The Veteran underwent a VA examination in September 2014 for his knee condition. The Veteran complained of increased pain, further loss of range of motion, and subjective weakness. He denied having any flare-ups. He had functional impairment in the form of less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting. The examiner opined that the Veteran's knee condition did not impact his ability to work. In an October 2014 VA examination for the Veteran's PTSD, the examiner described the Veteran's condition as causing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of instability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran described that for the past year and a half, he had been working part-time on weekends doing security at a gated community, working 24 to 32 hours on weekends. He stated that he worked alone so he had few problems at work and reported few absences. He also reported that in September 2014 he had earned an associate's degree as a medical assistant and would like to find work in that field, while continuing to volunteer at the hospice and home health organization where he did his clinicals in school. The examiner made findings that the Veteran had mild memory loss, such as forgetting names, directions, or recent events, depressed mood, anxiety, suspiciousness, and chronic sleep impairment. He was noted to shift his position frequently to ease pain and ambulated with a limp. The Veteran had mildly impaired recent memory and attention/concentration. However, his judgment and insight were fair, and his thought process and content were logical, organized, and relevant. He was capable of managing his own financial affairs. In an October 2014 VA examination for the Veteran's back condition, the examiner found that the Veteran's thoracolumbar spine condition impacted his ability to work. Specifically, the examiner found that the Veteran had stopped working full time, and now worked part time as a security guard due to pain in his knees and back. In an October 2014 research note, an employment specialist noted that the Veteran reported that he was working as a mental health technician. He reported that he was working the night shift, and had not had contact with his supervisor yet. He was primarily responsible for observing patients, helping to restrain patients where necessary, and doing vitals, temperatures, and rounds. The Veteran stated that he was working with the adult population at his job. The Veteran reported that he was working at a protective services company part time, 18-32 hours a week at 8 dollars an hour. He also reported that he had begun working at Behavioral Service on October 13, 2014, receiving 11 dollars per hour, 40 hours a week. In a March 2016 mental health note, the Veteran reported that work continued to go well despite his memory issues. He reported that he had developed systems to assist with his memory deficit such as getting support from providers and onsite management. The Veteran also reported a strong positive relationship with his site supervisor, manager, and clinical providers at the time. He was noted as being employed by The Red Cross as a phlebotomist from November 2014 to April 2015 and being employed with Med Help since June 2015. In a May 2016 mental health note, the Veteran reported that he continued to remain employed working in a walk-in medical clinic but felt that he must double and triple check everything he did at work which was both time consuming and exhausting. In an August 2016 mental health note, the Veteran reported that he worried that his fatigue and short-term memory problems would cause him to make critical errors at work, although this had not happened and the supervisor had voiced no dissatisfaction with the quality of the Veteran's work performance. The Veteran reported that he was fatigued during the day at work due to sleep disturbances. He also stated that after returning from work at night, he had difficulty relaxing enough to fall asleep. The Veteran submitted private treatment records regarding his back pain dated June 2016. In those records, the Veteran reported that he had back problems for more than 5 years and described the discomfort as severe. The Veteran did not endorse any aggravating factors. The Veteran did not report how the back pain impacted his employment, nor did the physician comment on the impact the Veteran's back pain had on his employability. In an October 2016 VA mental health note, the Veteran discussed stressors in his life affecting his PTSD and mood disorder outside of work. The Veteran reported that he was working at that time and was too exhausted afterwards to speak on the phone or to relatives. In the Veteran's May 2017 VA PTSD examination, the examiner determined that the Veteran's level of occupational and social impairment was described as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. In the examination, the Veteran also reported that his employment at the medical clinic was going fairly well. Nonetheless, he also reported that he had made some errors at work due to his focus and attention problems that his supervisor had brought to his attention. The Veteran expressed some concern about his job stability given his stated inability to certify or recertify for medical assisting and other positions. He also confirmed that he currently held a degree as a medical assistant. In a December 2017 mental health note, the Veteran reported losing his job of 2 and a half years at the medical clinic after missing a staff meeting and having an angry and frustrated demeanor when he met with his supervisor about it. At the time, the Veteran reported that he had enjoyed his work, but did not like the management style of his company. The Veteran submitted his application for compensation for increased compensation based on unemployability in May 2019. Therein, the Veteran confirmed that he worked as a security guard from January 2013 through December 2014 approximately 16 hours a week and at the American Red Cross from March 2014 through December 2014 approximately 20 hours a week. The Veteran also confirmed that his employment in the medical clinic was from June 15, 2015 to November 17, 2017. The Veteran reported that he was earning approximately 1,100 dollars per month. He has indicated that during his employment at the medical clinic, he lost approximately 1 year of employment due to his PTSD. In the Veteran's medical records there is a work excuse on July 16, 2016, but that instance was related to back pain. Unfortunately, there is no other evidence of record indicating that the Veteran missed up to 1 year of employment at the medical clinic due to his PTSD. After review of the record, the Board finds that a TDIU prior to November 18, 2017, is not warranted. The evidence indicates that while the Veteran has repeatedly reported back and knee pain during the period on appeal, the Board notes that the Veteran maintained employment for the period or otherwise attended college to obtain a degree in medical assisting. The Veteran was able to maintain gainful employment such as a security guard while he attended college, which he reported was a mostly non-physical job. Therefore, while for a period the Veteran was only working part-time, he was doing so in order to obtain an associate's degree, which he successfully obtained in September 2014. The Veteran's own statements and the evidence of record demonstrate that he was working full-time at a medical clinic until he was terminated November 18, 2017 due to his service-connected PTSD. The evidence does not indicate that this full-time employment was in a sheltered or protected environment. There was also no evidence that the Veteran had marginal employment during this time, as he worked full-time and earned $1,100 a month. See U.S. Census Bureau, Poverty Thresholds, https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html. Thus, the assigned effective date of November 18, 2017, the time at which the Veteran's employment ceased, is appropriate. While the Veteran reported struggling with his employment due to his PTSD prior to being terminated in November 2017, the evidence of record does not indicate the Veteran was unable to work due to his back, knee, and PTSD conditions, either individually or in aggregate, prior to November 18, 2017. Based on the above, the Board finds that the Veteran is not entitled to TDIU prior to November 18, 2017. Accordingly, the claim for TDIU is denied. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ford 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.