UNSPECIFIED TRAUMA AND STRESSOR RELATED DISORDER

ROYA BAHRAMI · 2022 · Case ID: 22000151

MIXED

Summary

The veteran, who served from June 1974 to July 1977, appeals the denial of service connection for an acquired psychiatric disorder other than unspecified trauma and stressor related disorder, and the denial of a higher rating for cephalgia. The veteran also appeals the denial of entitlement to Total Disability based on Individual Unemployability (TDIU). The Board granted a 70% rating for unspecified trauma and stressor related disorder and granted TDIU. The Board denied service connection for the acquired psychiatric disorder, finding the veteran did not have a current diagnosis of dysthymic disorder, and that the evidence preponderated against the claim. The Board also denied a higher rating for cephalgia, finding the evidence did not support characteristic prostrating attacks of headache pain with the frequency or severity required for a higher rating. For TDIU, the Board found the veteran met the schedular criteria based on his combined rating and the non-economic component of his service-connected disabilities, particularly his psychiatric condition and back issues, which impacted his ability to maintain substantially gainful employment.

Rationale

No current diagnosis of dysthymic disorder found; Preponderance of evidence against claim; VA exams diagnosed major depressive disorder and unspecified trauma and stressor related disorder; Private evaluation noted dysthymic disorder but VA exams did not; Veteran not competent to provide diagnosis

Special Benefit

TDIU

Docket No.

17-05 858A

Full Decision Text

Citation Nr: 22000151
Decision Date: 01/04/22 Archive Date: 01/04/22

DOCKET NO. 17-05 858A
DATE: January 4, 2022

ORDER

Entitlement to service connection for an acquired psychiatric disorder other than unspecified trauma and stressor related disorder (previously rated as depressive disorder with anxiety) is denied.

Entitlement to an initial compensable rating prior to October 21, 2020, and a rating in excess of 30 percent thereafter for cephalgia is denied.

Entitlement to an initial rating of 70 percent, but no higher, for unspecified trauma and stressor related disorder is granted.

Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted.

FINDINGS OF FACT

1. The preponderance of the evidence of record is against finding that the Veteran has had an acquired psychiatric disorder other than unspecified trauma and stressor related disorder at any time during or approximate to the pendency of the claim.

2. Prior to October 21, 2020, the evidence does not show that the Veteran's cephalgia was manifested by characteristic prostrating attacks of headache pain averaging one in two months; from October 21, 2020, the evidence indicates that his cephalgia was manifested by characteristic prostrating attacks of headache pain on an average once a month but without very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.

3. Since the effective date of the grant of service connection, the Veteran's unspecified trauma and stressor related disorder (previously rated as depressive disorder with anxiety) was manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood; it was not manifested by total occupational and social impairment.

4. Resolving any reasonable doubt in his favor, the Veteran is precluded from obtaining and maintaining gainful employment due his service-connected disabilities.

CONCLUSIONS OF LAW

1. The criteria for service connection for an acquired psychiatric disorder other than unspecified trauma and stressor related disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for a compensable rating prior to October 21, 2020, and a rating in excess of 30 percent thereafter for cephalgia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100.

3. The criteria for an initial rating of 70 percent for unspecified trauma and stressor related disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Codes 9413, 9434.

4. The criteria for a TDIU have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.400, 4.15, 4.16.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1974 to July 1977.

These matters come before the Board of Veterans' Appeals (Board) from a June 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO).

In June 2020, the Board remanded the issues currently on appeal, as well as entitlement to service connection for bilateral hearing loss and hepatitis C, for further development. The RO later granted service connection for bilateral hearing loss and hepatitis C in a July 2021 rating decision; those matters are no longer before the Board.

The Board notes that, in May 2021, the Veteran submitted a VA Form 20-0996 (Decision Review Request: Higher-Level Review). However, since the appeal was activated by the Board in March 2021, and the form was received after the Board activated the appeal, the opt-in is not valid. Accordingly, the Board will continue with adjudication pursuant to legacy appeals procedures.

1. Entitlement to service connection for an acquired psychiatric disorder other than unspecified trauma and stressor related disorder is denied.

The Veteran contends that he has a current diagnosis of dysthymic disorder that is related to his military service. See July 2015 notice of disagreement (NOD).

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §
activated by the Board in March 2021, and the form was received after the Board activated the appeal, the opt-in is not valid. Accordingly, the Board will continue with adjudication pursuant to legacy appeals procedures.

1. Entitlement to service connection for an acquired psychiatric disorder other than unspecified trauma and stressor related disorder is denied.

The Veteran contends that he has a current diagnosis of dysthymic disorder that is related to his military service. See July 2015 notice of disagreement (NOD).

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.

The Veteran's service treatment records are silent for any complaints of or a diagnosis of dysthymic disorder. His June 1974 enlistment and June 1977 separation examination reports noted normal psychiatric condition. He denied any depression or excessive worry in the June 1974 enlistment and May 1977 separation reports of medical history.

A July 2014 letter from private chiropractor P.Y. noted that the Veteran has posttraumatic stress disorder (PTSD). He added that the "aforementioned is in the process of being confirmed by the evaluation of the appropriately credentialed and licensed mental health professional who will publish an independent report."

An August 2014 private evaluation by Dr. W.A. noted diagnoses of major depressive disorder, dysthymic disorder, and generalized anxiety disorder. The Veteran reported he was a pretty shy person and had some difficulties with that transition. He reported he did not have many friends during his childhood and adolescence, although he was involved in sports activities including football, baseball, and diving. The Veteran reported that during basic training, he was punched by an unknown service member and lost his two front teeth. Dr. W.A. noted the Veteran had a "shy" childhood temperament. Dr. W.A. noted that the Veteran reported marked distress regarding his loss of teeth, a factor that had been embarrassing to him throughout his adult life. Dr. W.A. opined that the Veteran as likely as not developed symptoms of dysthymic disorder as a child, later meeting criteria for a major depressive episode during his military service. Dr. W.A. noted that the Veteran described experiencing troubles consistent with dysthymic disorder, a long-term depressive condition, as a child, and those difficulties intensified into recurrent major depressive disorder due to events which the Veteran was confronted during his military service. Dr. W.A. added that he as likely as not began to experience difficulties associated with generalized anxiety disorder during his military service. Dr. W.A. noted that psychopathology that developed during the Veteran's military service is based respectively on his account of his shame and distress regarding his loss of his two front teeth, his perceptions of helplessness, and on his account of excessive worry. Dr. W.A. noted that his conditions are inseparable, as is their respective impact upon the Veteran's social functioning.

In a January 2015 VA contract examination for PTSD, the Veteran was diagnosed with major depressive disorder, recurrent, moderate; and generalized anxiety disorder. The examiner noted that the Veteran did not meet the full criteria for PTSD. There was no other diagnosis of a psychiatric disorder.

In a June 2019 VA contract examination for PTSD, the Veteran was diagnosed with major depressive disorder, recurrent, moderate, with anxious distress. There was no other diagnosis. The examiner noted that the Veteran did not meet the criteria for a diagnosis of PTSD, and that his symptoms of anxiety and depression appear to be more consistent with a diagnosis of major depressive disorder, recurrent, moderate, with anxious distress. The examiner added that the Veteran has had several stressors which may have also contributed to his mood symptoms, to include homelessness and relationship problems.

Pursuant to the June 2020 Board remand, the Veteran underwent a VA contract examination for mental disorders in October 2020. The Veteran was diagnosed with unspecified trauma and stressor related disorder. No other diagnosis was made. The examiner noted that this new disorder appears to be a progression of the Veteran's service-connected disorder of depression with anxiety. The examiner also noted that the Veteran did not meet the criteria for a diagnosis
for a diagnosis of PTSD, and that his symptoms of anxiety and depression appear to be more consistent with a diagnosis of major depressive disorder, recurrent, moderate, with anxious distress. The examiner added that the Veteran has had several stressors which may have also contributed to his mood symptoms, to include homelessness and relationship problems.

Pursuant to the June 2020 Board remand, the Veteran underwent a VA contract examination for mental disorders in October 2020. The Veteran was diagnosed with unspecified trauma and stressor related disorder. No other diagnosis was made. The examiner noted that this new disorder appears to be a progression of the Veteran's service-connected disorder of depression with anxiety. The examiner also noted that the Veteran did not meet the criteria for a diagnosis of dysthymia or generalized anxiety disorder based on the current exam, as many of his symptoms overlap and are better accounted for the diagnosis of unspecified trauma and stressor related disorder.

Other than Dr. W.A.'s notation of dysthymic disorder in her evaluation, the Veteran's VA and private treatment records do not reveal a diagnosis of dysthymic disorder. The Veteran's VA treatment records intermittently mention PTSD, but there is no clinical diagnosis of PTSD.

After careful review of the evidentiary record, the Board concludes that the Veteran does not have a current diagnosis of an acquired psychiatric disorder other than unspecified trauma and stressor related disorder, previously rated as depressive disorder with anxiety, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007).

The Veteran contends that he has a diagnosis of dysthymic disorder based on Dr. W.A.'s evaluation. However, Dr. W.A. explained in the evaluation report that the Veteran as likely as not developed symptoms of dysthymic disorder as a child which later met the criteria for a major depressive episode in service. She noted that the Veteran described experiencing troubles consistent with dysthymic disorder as a child, and those difficulties intensified into recurrent major depressive disorder due to events in service. The January 2015 VA exam only noted diagnoses of major depressive disorder, recurrent, moderate; and generalized anxiety disorder. The examiner noted the Veteran did not meet the full criteria for PTSD. The June 2019 VA exam noted a single diagnosis of major depressive disorder, recurrent, moderate with anxious distress. The examiner also noted that the Veteran did not meet the criteria for a diagnosis of PTSD, and that his symptoms of anxiety and depression appeared more consistent with the major depressive disorder diagnosed. The October 2020 VA exam performed pursuant to the Board remand noted a single diagnosis of unspecified trauma and stressor related disorder, which the examiner explained was a progression of the Veteran's depression with anxiety. The examiner also explained that the Veteran did not meet the criteria for a diagnosis of dysthymia or generalized anxiety disorder based on the current exam as many of his symptoms overlap and are better accounted for the diagnosis of unspecified trauma and stressor related disorder. Given the foregoing, the Board concludes that the Veteran does not have a diagnosis of an acquired psychiatric disorder other than unspecified trauma and stressor related disorder, previously rated as depressive disorder with anxiety.

While the Veteran believes he has a current diagnosis of dysthymic disorder, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence.

The Board has considered Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the Federal Circuit explained that where pain alone results in functional impairment that affects earning capacity, even if there is no identified underlying diagnosis, it can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). Here, the Veteran has not asserted nor provided objective evidence that his claimed dysthymic disorder results in functional impairment that affects his earning capacity. Thus, the Board does not find that his claimed dysthymic disorder rises to the level of a disability under Saunders.

The Board also notes that the Veteran is already being compensated for a service-connected psychiatric disorder, diagnosed as unspecified trauma and stressor related disorder. Under VA law and regulations, a veteran may only receive a single disability rating for psychiatric disabilities as all psychiatric disorders and symptoms are rated under the General Rating
it can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). Here, the Veteran has not asserted nor provided objective evidence that his claimed dysthymic disorder results in functional impairment that affects his earning capacity. Thus, the Board does not find that his claimed dysthymic disorder rises to the level of a disability under Saunders.

The Board also notes that the Veteran is already being compensated for a service-connected psychiatric disorder, diagnosed as unspecified trauma and stressor related disorder. Under VA law and regulations, a veteran may only receive a single disability rating for psychiatric disabilities as all psychiatric disorders and symptoms are rated under the General Rating Formula for Mental Disorders, and to assign separate ratings for acquired psychiatric disorders would constitute pyramiding. 38 C.F.R. § 4.14. Thus, even if service connection were granted for another psychiatric disorder, he would not receive any additional compensation.

In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for an acquired psychiatric disorder other than depressive disorder with anxiety is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Entitlement to an initial compensable rating prior to October 21, 2020, and a rating in excess of 30 percent thereafter for cephalgia is denied.

The June 2015 rating decision on appeal awarded service connection for cephalgia and assigned an initial noncompensable rating effective July 31, 2014. The Veteran subsequently asserted that he is entitled to a higher rating. See July 2015 NOD. In January 2021, the RO increased the rating to 30 percent effective October 21, 2020. As this was not a full grant of the benefit sought, the matter remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The appeal period begins on the effective date of service connection.

The Veteran's cephalgia is rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8100, for migraine. Under DC 8100, a noncompensable rating is warranted for migraines with less frequent attacks. A 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months.

The rating criteria of DC 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). This renders 38 C.F.R. §§ 4.7 and 4.21 inapplicable. Johnson, 30 Vet. App. at 252.

The phrase "characteristic prostrating attacks" is used in the criteria corresponding to 10 percent and 30 percent ratings under DC 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland's Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as "extreme exhaustion or powerlessness." Thus, the phrase "characteristic prostrating attacks" is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness.

The rating criteria for a 50 percent rating contain several undefined phrases. The descriptive phrase "very frequent" connotes a frequency at least greater than once a month, as is required by the rating criteria corresponding to a lesser 30 percent rating. Johnson, 30 Vet. App. at 253. The phrase "completely prostrating" generally means that the migraines attack must render the veteran entirely powerless. Id. The completely prostrating attacks must also be "prolonged," which is defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. (internal citation omitted). Lastly, the 50 percent rating criteria requires that the very frequent completely prostrating and prolonged attacks be "productive of severe economic inadaptability." Productive can be read as having either the meaning of "producing" or "capable of producing," and, with regard to severe economic inadaptability, nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440,
. The completely prostrating attacks must also be "prolonged," which is defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. (internal citation omitted). Lastly, the 50 percent rating criteria requires that the very frequent completely prostrating and prolonged attacks be "productive of severe economic inadaptability." Productive can be read as having either the meaning of "producing" or "capable of producing," and, with regard to severe economic inadaptability, nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004).

A July 2014 private statement from a chiropractor noted that the Veteran has daily headaches that are constantly present unless medicated.

A December 2014 VA treatment record the Veteran was positive for headaches, and "chronic daily headaches" was noted.

At a January 2015 VA contract examination for PTSD, the Veteran reported he had daily headaches which he believed were due to the punch/fall incident in service.

In January 2015, the Veteran underwent a VA examination for headaches. He was diagnosed with tension and muscular headaches. The examiner noted that the Veteran's treatment plan did not include taking medication for the diagnosed condition. The examiner noted the Veteran experienced constant head pain on both sides of the head which worsened with physical activity. The examiner noted dizziness and vertigo as the associated symptoms. The duration of typical headache pain was less than 1 day, located on both sides of the head. The examiner noted the Veteran did not have characteristic prostrating attacks of headache pain. The examiner also noted his headache condition did not impact his ability to work.

VA treatment records dated April 2015, May 2015, May 2016, November 2016, December 2016, December 2017, December 2018, December 2019, and September 2020 note that the Veteran denied headaches.

At a October 2020 VA contract examination for headaches, the Veteran was diagnosed with cephalgia. He reported the condition began after falling down the stairs in 1974 and bumping his head. The examiner noted the Veteran's treatment plan includes taking Tylenol. The examiner noted the Veteran experienced pulsating or throbbing head pain on both sides of the head which worsened with physical activity. Nausea, changes in vision, and dizziness were noted as the associated symptoms. The examiner noted the duration of the typical head pain was 1 to 2 days on both sides of the head. The examiner noted the Veteran had characteristic prostrating attacks of headache pain once every month. He did not have any very prostrating and prolonged attacks of headache pain productive of severe economic inadaptability. The examiner noted the Veteran's headaches impacted his ability to work in that he experienced difficulties with concentrating on tasks during attacks.

At a December 2020 VA contract examination for headaches, the Veteran was diagnosed with cephalgia. The Veteran reported he had headaches every day. The examiner noted the Veteran's treatment plan included taking BC powder or Tylenol. The examiner noted the Veteran had pulsating throbbing head pain in the back of the head and mid neck. The examiner noted there were no other symptoms associated with the headaches. The typical headache lasted less than a day. The examiner noted the Veteran did not have characteristic prostrating attacks of headache pain. The examiner opined the headaches did not impact his ability to work.

After review of the evidentiary record, the Board concludes that the preponderance of the evidence is against the assignment of higher ratings at any time during the appeal period.

Prior to October 21, 2020, the Veteran's VA and private treatment records are silent for characteristic prostrating attacks of headache pain. The Veteran reported daily headaches at the July and December VA treatments, the July 2014 visit to his chiropractor, and the January 2015 VA examination for PTSD. However, there is no indication that he suffers from "characteristic prostrating attacks," which is understood to describe headache attacks that typically produce extreme exhaustion or powerlessness. None of the aforementioned reports of headaches are described as characteristic prostrating attacks. Further, the January 2015 examiner noted the Veteran did not have characteristic prostrating attacks, and the Veteran consistently denied any headaches from April 2015 to September 2020. As the Veteran's VA and private treatments are silent for characteristic prostrating attacks of headache pain prior to October 21, 2020, a compensable rating prior to October 21, 2020 is not warranted. 38 C.F.R. § 4.124a, DC 8100.

From October 21, 202
from "characteristic prostrating attacks," which is understood to describe headache attacks that typically produce extreme exhaustion or powerlessness. None of the aforementioned reports of headaches are described as characteristic prostrating attacks. Further, the January 2015 examiner noted the Veteran did not have characteristic prostrating attacks, and the Veteran consistently denied any headaches from April 2015 to September 2020. As the Veteran's VA and private treatments are silent for characteristic prostrating attacks of headache pain prior to October 21, 2020, a compensable rating prior to October 21, 2020 is not warranted. 38 C.F.R. § 4.124a, DC 8100.

From October 21, 2020, the only evidence that shows characteristic prostrating attacks is the October 2020 VA contract examination. In the exam, the examiner was requested to answer whether the Veteran had any characteristic prostrating attacks of headache pain, and if so, to indicate the frequency, on average, of prostrating attacks over the last several months. The examiner noted the Veteran experienced it once every month. However, as noted above, the Veteran's records are silent for any complaints of headaches, much less characteristic prostrating attacks, several months prior to the exam. The subsequent examination in December 2020 found that the Veteran did not have any characteristic prostrating attacks of headache pain. Given the isolated nature of the October 2020 exam's finding of characteristic prostrating attacks once a month, the Board affords such finding little to no probative weight. However, the Board will not disturb the RO's assignment of the 30 percent rating. In light of the foregoing, the Board finds that a rating in excess of 30 percent is not warranted from October 21, 2020. Id.

The evidence does not show that the Veteran's cephalgia have manifested in or more nearly approximated very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability from October 21, 2020. While the October 2020 examiner noted that the Veteran's cephalgia impacts his ability to work, the examiner did not endorse prostrating and prolonged attacks productive of severe economic inadaptability. The December 2020 examiner also did not endorse prostrating and prolonged attacks productive of severe economic inadaptability.

In conclusion, the Board finds that the criteria for an initial compensable rating prior to October 21, 2020, and a rating in excess of 30 percent thereafter for cephalgia have not been met. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3.

3. Entitlement to an initial rating of 70 percent, but no higher, for unspecified trauma and stressor related disorder is granted.

The Veteran contends that he is entitled to a higher rating for his psychiatric disability. See July 2015 NOD. The appeal period before the Board begins on July 31, 2014, the effective date of service connection.

The Veteran's psychiatric disability is rated under DC 9434 prior to October 20, 2020, and under DC 9413 thereafter. Both codes are rated pursuant to the General Formula for Mental Disorders (General Formula). Under the General Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013).

The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher.

The Board concludes that, resolving any doubt in the Veteran's favor, the Veteran's psychiatric symptoms caused the level of impairment required for a disability rating of 70 percent throughout the appeal period.

A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or
2013).

The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher.

A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.

A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name.

A June 2014 VA treatment record noted that the Veteran denied current anxiety, depression, or suicidal ideation. A July 2014 VA treatment record noted that the Veteran reported that he would be homeless the next day because he was notified two months prior that he needed to be out of his apartment by beginning of August. He reported he was depressed but not suicidal.

In an August 2014 private evaluation, Dr. W.A. noted the following diagnoses: major depressive disorder, dysthymic disorder, and generalized anxiety disorder. The Veteran reported his mood was "not very good" most of the day, nearly every day. He described anhedonia in the form of his social isolation. He reported insomnia in the form of difficulty with sleep onset and intermittent waking. He reported significant experiences of fatigue and loss of energy. He described feelings of worthlessness and guilt in part due to his loss of job in plumbing. The Veteran stated that the loss of two front teeth in service was a factor that had been embarrassing to him throughout his adult life. He stated he desired to be dead sometimes as "I'm not doing anybody any good;" however, he denied suicidal or homicidal means, plans, time frame, and intent. He displayed substantial difficulties with worry, and with controlling the worry. Dr. W.A. noted that his psychomotor retardation was markedly apparent. She noted his cognitive difficulties, including the diminished ability to think and indecisiveness, were apparent, as were concentration problems.

On mental status examination, the Veteran was pleasant and cooperative. His impulse control appeared to fall below normal limits based upon his difficulties with tolerating others to such an extent that he preferred to be homeless. Speech was unusually soft and slow, but normal in content. Form of thought was circumstantial. The Veteran's thought content was consistent with presence of an intermittent wish to die, but without active suicidal or homicidal ideation. He stated his mood at the time of the evaluation was a lot better than prior to the interview. His affect was blunted though stable. The Veteran was oriented times three. His attention capacities and concentration abilities fell below normal limits. His immediate memory, memory for recent events, and memory for recent past events appeared normal. Remote memory was intact. Intelligence and fund of information appeared average. Judgement and insight appeared to fall below normal limits.

A December 2014 VA treatment record noted that the Veteran was reportedly living out of his car and using a gym to shower. The clinician noted the Veteran had a depressed affect but overall was well developed and well groomed.

At a January 2015 VA contract examination, the Veteran was diagnosed with major depressive disorder, recurrent, moderate; and generalized anxiety disorder. He reported he has a biological daughter and two stepchildren from his first marriage. He was reportedly close to his daughter and talked occasionally to one of the stepchildren. He stated he spent time with his one friend a few times a month, and that he joined a gym so that he had a place to take a shower. At the time of the examination, he was working at a golf club clubhouse. Symptoms included depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, passive death wishes without current suicidal ideation, tendency to isolate from others, feelings of worthlessness, low energy, anhedonia, difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. No behavioral observations were noted. The Veteran was capable of managing his financial affairs. The examiner found that the Veteran's symptoms resulted in 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.

An April 2015 VA treatment record noted that the Veteran reported he was still living out of his car and using the gym to shower. He had a depressed affect but overall was well developed and well groomed. Review of psychiatric system was negative for depression or anxiety.

A November 2015 VA treatment record noted that the Veteran denied anxiety, depression, suicidal or homicidal ideation, or hallucination.

During treatment in May 2016, the Veteran denied anxiety, depression, suicidal or homicidal ideation, or hallucination.

A December 2016 VA record reflects that the Veteran denied feeling down, depressed, or hopeless. He denied thoughts that he would be better off dead or of hurting himself in some way.

During treatment in December 2017, the Veteran reported depression that was worsening. He stated he did not want to be around people, was impatient, and was withdrawn. He stated he was tempted to begin drinking alcohol again. He denied suicidal or homicidal ideation.

A July 2018 VA treatment record noted the following symptoms for his depression: low self-confidence, anhedonia (not enjoying golf and "makes me mad that I don't enjoy it."), low motivation, sadness, depressed mood, and passive thoughts of death. It noted the following symptoms for anxiety: he "worries about things [he] shouldn't even worry about;" and difficulty redirecting his attention to something else. He indicated thoughts of escape or passive thoughts of death. He denied current and recent suicidal thoughts, plan, and intention, and identified several protective factors.

An August 2018 VA psychiatry note indicated that the Veteran reported feeling less motivated, apathetic, and more isolative. He reportedly avoided social events and had poor sleep. He endorsed some anxiety. The Veteran denied mania, psychosis, or suicidal or homicidal ideation. He still lived alone and worked as a golf teacher. On mental status exam, he displayed the following: alert appearance; calm motor activity; cooperative attitude; normal speech; depressed mood; restricted affect; normal attention and concentration; normal recent and remote memories; normal linear, and goal-oriented thought process; and fair judgment and insight. He was appropriately dressed, oriented to person, place, situation, and date, and had no auditory or visual hallucinations.

At a June 2019 VA contract examination for PTSD, the Veteran was diagnosed with major depressive disorder, recurrent, moderate, with anxious distress. He reported a distant relationship with his daughter as he often felt ashamed and felt like a burden on others. He had no significant social support system. He did not attend social gatherings regularly. He stated he was homeless and had been living in his car for almost two years. He reported his daily routine consisted of working part-time at a golf course and teaching golf. He was able to bathe, dress, and use the toilet independently. He had a valid driver's license and was able to drive independently without difficulty. He was able to prepare basic food such as sandwiches and microwave meals without assistance. He reported depressed mood, feeling useless, and that he does not like to be around people. He endorsed problems with initiating sleep and with diminished appetite. He denied any current nightmares. He often felt overwhelmed but does not experience any panic attacks. The Veteran had thoughts of death but with no current suicidal or homicidal ideation, intent or plan. He did not experience any psychosis
living in his car for almost two years. He reported his daily routine consisted of working part-time at a golf course and teaching golf. He was able to bathe, dress, and use the toilet independently. He had a valid driver's license and was able to drive independently without difficulty. He was able to prepare basic food such as sandwiches and microwave meals without assistance. He reported depressed mood, feeling useless, and that he does not like to be around people. He endorsed problems with initiating sleep and with diminished appetite. He denied any current nightmares. He often felt overwhelmed but does not experience any panic attacks. The Veteran had thoughts of death but with no current suicidal or homicidal ideation, intent or plan. He did not experience any psychosis such as hallucinations or delusions. He endorsed feeling paranoid "that something is going to happen, or someone is going to break in." His affect appeared restricted. He reported his present conditions are impacted by current financial difficulties. The examiner noted the following symptoms: depressed mood; anxiety; chronic sleep impairment; impaired judgment; disturbances of motivation and mood; and difficulty adapting to stressful circumstances, including work or a worklike setting.

On behavioral observation, the Veteran was alert and oriented to person, place, situation, and time. He did not display any significant problems with motor functioning. His speech was unremarkable in rate and quality. He demonstrated fair attention, concentration, and mental flexibility. Receptive and expressive language appeared to be fair. General thought processes appeared to be coherent, logical, and goal-directed. Thought form and content appeared age appropriate and unremarkable. The Veteran denied having any suicidal or homicidal ideations. He was capable of managing his financial affairs. The examiner opined that the Veteran's psychiatric disorder caused 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.

A March 2020 VA treatment record noted that the Veteran continued to work part-time at a golf range. He continued to live alone in a travel trailer. He reported minimal socialization outside of work. The Veteran stated that he had been irritable at work lately. He endorsed anhedonia. There was no mania, hypomania, hallucinations, delusions, or paranoia. He adamantly denied any thoughts or plans or means to harm or kill himself or anyone else. On mental status examination, the Veteran appeared alert, dressed appropriately, and with no acute distress. His motor activity was calm. He was cooperative. His speech was normal in rate and volume. Mood was depressed, irritable, and anxious. Affect was broad, and mood was congruent. He had normal attention and concentration. He had normal recent and remote memory. His thought process was normal, linear, and goal-oriented. He had no auditory or visual hallucinations, or delusional thoughts. He had good judgment and insight. He was oriented to person, place, situation, and date.

A May 2020 VA treatment record noted that the Veteran indicated increased stress related to his boss being "greedy" and having to change procedures due to COVID. He explained feeling very dissatisfied with his work and extra demands, and is now putting in more hours. The Veteran indicated he would like to retire, but was worried about finances. He stated his dissatisfaction with his work was starting to impact how he worked with his clients.

A June 2020 VA record reflects that the Veteran continued to experience stressors at work. He stated he really wanted to quit, and that he was making mistakes and did not have the same level of care or passion about his job. The Veteran stated that this is particularly due to his boss and the environment he created. He stated he could get by financially, but it would be tight and he needed to pay off some debts. He also indicated he needed to get final paperwork regarding a divorce so he could start collecting pension from the resort company he used to work for.

An August 2020 VA record noted that the Veteran reported he retired. He stated the conversation he had with his boss was not as bad as he thought it would be. He indicated that work stress and increasing demands contributed to his decision to retire. He stated that his boss asked him if he would like to work on Saturday mornings to help set up, and that he agreed as this would be relatively stress free. He indicated that his retirement has allowed him to spend more time with his grandchildren. He stated he purchased some golf equipment, so that he could practice at home.

At an October 2020 VA contract examination for mental disorders, the Veteran was diagnosed with unspecified trauma and stressor related disorder. He reported a distant relationship with his children. He had one close friend but was not involved in any social activities. The Veteran did not call or communicate with anyone unless they reached out first. He reported he stopped working due to "anxiety and mental stress." He stated he often felt overwhelmed with dealing with customers and described his boss as a "micromanager." He stated that he was unable to work because "I cannot handle people anymore and my mood changes." He reported that he owned a bar in 2001 where three people were murdered. He stated he witnessed the murder and was in part of cleaning up the aftermath. Since that incident, his anxiety has increased and he does not engage in social functions. The examiner noted the following symptoms: depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty adapting to stressful circumstances, including work or a worklike setting.

On behavioral observation, the Veteran was alert and oriented times four. He was neat and clean in appearance. Thought processes appeared organized and logical. Affect was flat. Speech was clear. Insight and judgment appeared intact. Eye contact was adequate. The Veteran was polite and cooperative. He was capable of managing his financial affairs. The examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity.

An October 2020 VA treatment record noted that the Veteran reported "I'm holding steady." He was retired but worked 1 day a week. He reported playing golf at times and spending time with grandchildren. He still endorsed depressive and anxiety symptoms, but his mood was stable overall. He denied any thoughts to harm himself or anyone else. His speech, memory, judgment, attention, and thought process were normal.

A January 2021 VA treatment record noted that the Veteran felt he did not have anything to do. He denied thinking about harming or killing himself or anyone else. He reported depression and anxiety. He was feeling tired and had no energy. He denied guilt or worthlessness. His speech, memory, judgment, attention, and thought processes were normal. He was oriented to person, place, situation, and date.

In November 2021, VA received a private psychiatric evaluation from psychologist C.M. She noted she reviewed the entire VA claims file and treatment records, and performed a videoconference interview in November 2021. She opined that based on her careful review of the record, her professional experience, and her clinical interview with the Veteran, the Veteran's service-connected psychiatric disability is chronic and severe, and has at least as likely as not caused him occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood, since at least July 2014 to the present. She noted that the Veteran endorsed the following psychiatric symptoms: recurrent thoughts; intense or prolonged distress as well as marked physiologic reactivity after exposure to traumatic reminders; avoidance; negative emotional state; alienation; constricted affect; irritable behavior; exaggerated startle response; problems with concentration; sleep disturbance; depressed mood; fatigue or loss of energy; feelings of worthlessness or guilt; recurrent thoughts of death; anxiety; suspiciousness; near-continuous depression affecting the ability to function independently, appropriately, and effectively; impairment of short- and long-term memory, such as retention of only highly learned material while forgetting to complete tasks; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances in including work or a work-like setting; inability to establish and maintain effective relationships; obsessional rituals which interfere with routine activities; and impaired impulse control, such as unprovoked irritability with periods of violence.

After careful review, the Board finds that the Veteran's unspecified trauma and stressor related disorder, previously rated as depressive disorder with anxiety, manifested with symptoms causing occupational and social impairment that more closely aligns with the 70 percent rating criteria under the General Formula during the appeal period.

The Veteran's VA treatment records and VA and private evaluations show that the Veteran's psychiatric disorder was manifested by the following symptoms during the appeal period: depressed mood; chronic sleep impairment; suspiciousness; anxiety; impaired judgment; mild memory loss; flattened affect; disturbances of motivation and mood;
-like setting; inability to establish and maintain effective relationships; obsessional rituals which interfere with routine activities; and impaired impulse control, such as unprovoked irritability with periods of violence.

The Veteran's VA treatment records and VA and private evaluations show that the Veteran's psychiatric disorder was manifested by the following symptoms during the appeal period: depressed mood; chronic sleep impairment; suspiciousness; anxiety; impaired judgment; mild memory loss; flattened affect; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. These symptoms are contemplated by 30 percent to 50 percent evaluation under the General Formula. See 38 C.F.R. § 4.130.

The Veteran also displayed other symptoms such as tendency to isolate from others, feelings of worthlessness, thoughts of death, impaired impulse control, and difficulty adapting to stressful circumstances in including work or a work-like setting. He stated in the August 2014 private evaluation that he sometimes desired to be dead. He reported at the January 2015 VA exam that he had passive death wishes, and he had difficulty in adapting to stressful circumstances. A December 2017 VA record noted he did not want to be around people, was impatient, and was withdrawn. A July 2018 VA record noted he had thoughts of escape or passive thoughts of death. At the June 2019 VA exam, he reported thoughts of death and his symptoms included difficulty adapting to stressful circumstances. At the October 2020 VA exam, he stated he often felt overwhelmed with dealing with customers, and that he was unable to work because "I cannot handle people anymore and my mood changes." One of the symptoms noted was difficulty adapting to stressful circumstances. The November 2021 private evaluation noted numerous symptoms including recurrent thoughts of death, near-continuous depression affecting the ability to function independently, appropriately, and effectively, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, and impaired impulse control. The records show that the Veteran displayed some symptoms commensurate with the 70 percent rating criteria under the General Formula throughout the appeal period. In light of the foregoing, the Board finds that evidence overall demonstrates the level of occupational and social impairment associated with a 70 percent rating.

The evidence does not reflect total social impairment during the appeal period. The Veteran has a valid driver's license and can drive by himself; he can bathe, dress, and use toilet independently; he can prepare basic food such as sandwiches and microwave meals without assistance; he can teach golf and perform basic office work; his speech was always normal and he displayed good judgment. Further, he denied any delusions or hallucinations; he did not display gross impairment in thought processes or communication or grossly inappropriate behavior; and he does not have memory loss for names of close relatives, own occupation, or own name. Indeed, the examiners during the appeal period summarized the Veteran's level of occupational and social impairment with regards to all mental diagnoses as, at worst, occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Thus, the Veteran's symptoms do not demonstrate the level of impairment required for a 100 percent rating.

In short, the evidence is at least in equipoise as to whether a 70 percent rating is warranted throughout the appeal period; the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. A rating of 70 percent, but no higher, for unspecified trauma and stressor related disorder is warranted from the effective date of the grant of service connection, which is July 31, 2014.

4. Entitlement to a TDIU is granted.

The Veteran contends that his service-connected psychiatric disability, headaches, and back condition prevent him from securing or following any substantially gainful occupation. See June 2019 VA Form 21-8940; August 2020 VA Form 21-8940. The appeal period begins from June 7, 2019, the date VA received the claim for a TDIU.

Total disability ratings for compensation may be assigned when a veteran is unable to secure and follow a substantially gainful occupation. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. Section 4.16(a) provides a rating hurdle for schedular consideration of a TDIU. Where the schedular rating is less than total, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. To meet the requirement of the 60 percent disability or the 40 percent disability, the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id.

The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a veteran's ability to secure and follow such employment. Id. Attention should be given to the veteran's history, education, skills, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, 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 (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. Factors such as age or impairment by non-service-connected disabilities are not to be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19.

The fact that a Veteran is unemployed or has difficulty obtaining employment is not enough, as a schedular rating provides recognition of such. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The schedular criteria contemplate compensating a Veteran for considerable loss of working time from exacerbations proportionate to the severity of the disability. 38 C.F.R. § 4.1. The ultimate question is whether the Veteran, because of service-connected disabilities, is incapable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose, 4 Vet. App. at 363.

In this case, the Veteran is service connected for: unspecified trauma and stressor related disorder (50 percent from July 31, 2014); degenerative arthritis of the lumbar spine (40 percent from July 31, 2014); degenerative arthritis of the cervical spine (30 percent from July 31, 2014); cephalgia (0 percent from July 31, 2014; 30 percent from October 21, 2020); tinnitus (10 percent from July 31, 2014); radiculopathy, right lower extremity (10 percent from June 27, 2019); radiculopathy, left lower extremity (10 percent from June 27, 2019); bilateral hearing loss (0 percent from July 31, 2014); and hepatitis C (0 percent from July 31, 2014).

His combined rating is 80 percent from July 31, 2014, and 90 percent from June 27, 2019. From June 7, 2014, the Veteran is in receipt of an 80 percent combined rating with at least one disability ratable at 40 percent or more. Thus, he meets the schedular criteria for a TDIU. See 38 C.F.R. § 4.16(a).

The Veteran's Form DD 214 notes that his military occupational duty was lineman.

In the June 2019 VA Form 21-8940, the Veteran noted that his
2014); and hepatitis C (0 percent from July 31, 2014).

The Veteran's Form DD 214 notes that his military occupational duty was lineman.

In the June 2019 VA Form 21-8940, the Veteran noted that his depressive disorder with anxiety prevents him from securing or following substantially gainful employment. He noted the date his disability affected full-time employment was July 7, 2011; the date he last worked full-time was June 14, 2012; and that the date he became too disabled to work was June 3, 2012. He noted the most he has ever earned was $32,000 in 2012 as a commercial plumber. He noted that he had been working at a golf club since February 14, 2014 doing clerk work 22 hours a week, earning $980 per month. He noted that the total income earned for the past 12 months was $11,000. He noted he completed 2 years of college. He noted he had education in golf complex operation and management from May 2012 to December 2013. He noted in the remarks that he has a part-time job which he is "very uncomfortable dealing with people and [his] lock of concentration is minimum."

In his June 2019 VA contract examination for PTSD, the Veteran was diagnosed with major depressive disorder, recurrent, moderate with anxious distress. He reported he was a part-time golf instructor, and his daily routine consists of working part-time at a golf course and teaching golf. He reported his employment history included knife instructor, room service waiter, and plumber. He stated his last job occurred in 2012 as a plumber which ended because of physical limitations. He reported the longest job was from 1984 to 1995 as a room service waiter for a Disney resort in Polynesia. He stated he had a valid driver's license and was able to drive independently without difficulty. The examiner summarized the Veteran's level of occupational and social impairment with regards to his mental diagnosis 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 his June 2019 VA contract examination for back conditions, the Veteran was diagnosed with degenerative arthritis of the spine, intervertebral disc syndrome, and bilateral lower extremity radiculopathy. The Veteran reported difficulties with bending. The examiner noted that his back condition impacted his ability to work in that he cannot lift over 40 pounds for prolonged periods of time due to pain.

In a June 2019 VA examination for neck conditions, the Veteran was diagnosed with degenerative arthritis of the spine. The Veteran reported he had difficulties turning his back side to side. The examiner noted that his cervical condition impacted his ability to work in that he could not lift over 40 pounds for prolonged periods of time due to pain and limited neck rotation.

In an August 2019 VA Form 21-4138, the Veteran stated that his psychiatric condition and back problems had worsened over the years. He stated he can no longer work a full-time job. He stated he had been working 20 hours a week, 4 hours a day as a behind-the-counter cashier at a golf course, but his achieving duties and performance were becoming difficult. He stated he could no longer stand more than an hour at a time and could barely move due to his back problems. He stated he was having memory loss and trouble with figures for the last several years. He stated he was taking medicine prescribed from his psychologist just to cope a little bit. He had been going to psychologist for the last 2 years, but did not seem to be getting better. He stated he has no social interaction, no friends, and lived alone. He stated he was short with everybody and did not like to be around people.

In a September 2019 VA Form 21-4192, the Veteran's golf club employer noted that the Veteran had been working at the club since February 14, 2014 doing light duties such those of a cashier or a golf attendant. It noted the Veteran earned $11,537 during the preceding 12 months, and worked 5 hours daily, 20 hours weekly. It noted the employer made the following concessions to the Veteran: "not allowed to lift anything heavy due to his condition[;] can't
2 years, but did not seem to be getting better. He stated he has no social interaction, no friends, and lived alone. He stated he was short with everybody and did not like to be around people.

In a September 2019 VA Form 21-4192, the Veteran's golf club employer noted that the Veteran had been working at the club since February 14, 2014 doing light duties such those of a cashier or a golf attendant. It noted the Veteran earned $11,537 during the preceding 12 months, and worked 5 hours daily, 20 hours weekly. It noted the employer made the following concessions to the Veteran: "not allowed to lift anything heavy due to his condition[;] can't work over 4 hrs. a day[;] stand only 1 hours at a time[;] staying focused."

In a March 2020 VA treatment record, the Veteran reported he continued to work part-time at a golf range. He reported he continued to live alone in a travel trailer. He stated that he has been irritable at work lately.

In a May 2020 VA treatment record, the Veteran indicated increased stress related to his boss being "greedy" and having to change procedures due to COVID. He explained feeling very dissatisfied with his work and extra demands, and was now putting in more hours. The Veteran indicated he would like to retire, but was worried about finances. He indicated his dissatisfaction with his work is starting to impact how he works with his clients.

In a June 2020 VA record, the Veteran indicated that he continued to experience stressors at work. He stated he really wanted to quit, and that he was making mistakes and did not have the same level of care or passion about his job. He stated that this was particularly due to his boss and the environment he created. He indicated that he continued to experience stressors at work.

In an August 2020 VA record, the Veteran reported that he finally retired. He stated that his boss asked him if he would like to work on Saturday mornings to help set up, and that he agreed as this will be relatively stress free.

In an August 2020 VA Form 21-8940, the Veteran noted his anxiety, depression, migraines, and back pain prevented him from securing or following any substantially gainful occupation. He noted the date his disability affected full-time employment was June 2010; the date he last worked full-time and the date he became too disabled to work full-time was July 2, 2012. He noted that the most ever earned in one year was $30,854 in 2010 as a plumber's helper. He noted he worked at a golf club as a front desk cashier and staff instructor from February 14, 2014 to July 31, 2020, working 24 hours a week, earning $1,273 a month. He noted the total earned in the past 12 months was $15,275. He noted he left his employment because of his disability and did not expect to receive disability benefits. He noted he has not tried to obtain employment since he became too disabled to work. He noted in the remarks that he has to take so much medicine just to cope. He stated he took medicine for the following conditions: mood; anxiety; sleep; back pain; migraines; gastroenteric problems. He noted his doctor said if he did not take all this medicine, he would not be able to work part-time. He noted that he was unable to work mentally, cannot tolerate to be around people, and very short-tempered, which affected everything he does. He noted he is physically unable to work and cannot stand or sit for periods of time because of back pain and migraines which brings on nausea, dizziness, and gastroenteritis problems.

At an October 2020 VA contract examination for mental disorders, his last reported employment was a golf instructor from 2014 to 2020. He reported he stopped working due to "anxiety and mental stress." He stated he often felt overwhelmed with dealing with customers and described his boss as a "micromanager." He stated that he is unable to work because "I cannot handle people anymore and my mood changes." The examiner summarized the Veteran's level of occupational and social impairment with regard to his mental diagnosis as occupational and social impairment with reduced reliability and productivity.

At the October 2020 VA contract examination for liver conditions, the Veteran was diagnosed with hepatitis C. The examiner noted his liver condition did not impact his ability to work.

At the October 2020 VA contract examination for headaches, the Veteran was diagnosed with cephalgia. The examiner noted the Veteran's headaches impact his ability to work in that he experiences difficulties with concentrating on tasks with attacks.

At the December 2020 VA contract examination for liver conditions, the Veteran was diagnosed with nonal
." He stated that he is unable to work because "I cannot handle people anymore and my mood changes." The examiner summarized the Veteran's level of occupational and social impairment with regard to his mental diagnosis as occupational and social impairment with reduced reliability and productivity.

At the October 2020 VA contract examination for liver conditions, the Veteran was diagnosed with hepatitis C. The examiner noted his liver condition did not impact his ability to work.

At the December 2020 VA contract examination for liver conditions, the Veteran was diagnosed with nonalcoholic steatohepatitis liver disease and history of hepatitis C. The examiner noted his liver condition did not impact his ability to work.

At the December 2020 VA contract examination for headaches, the Veteran was diagnosed with cephalgia. The examiner noted the headache does not impact his ability to work.

In a February 2021 VA Form 21-4192, the Veteran's golf club employer noted that the Veteran worked from February 14, 2014 to July 31, 2020 as a front desk cashier. It noted he earned $13,559 during the 12 months preceding the last date of employment. It noted he now worked six hours in a week. Concessions made to the Veteran were the following: staying focused; temperament around guests; over reactions; anxiety; and trouble concentrating. The reason for termination was, "could no longer do his [job effectively]; use him as a starter only 6 hours a week." The last date of payment was in December 2020 for $54.63.

In a November 2021 private evaluation, psychologist C.M. noted that she believed the Veteran's service-connected unspecified trauma and stressor related disorder has at least as likely as not rendered him fully unable to successfully secure and follow substantially gainful employment since at least July 2014. She noted that the Veteran's occupational impairment is evidence by his limitations including: issues sustaining concentration; difficulty managing trauma triggers and resulting anxiety symptoms; negative affect; low motivation; social isolation; difficulty tolerating interaction with others; low frustration tolerance and irritability; near-continuous depression affecting his ability to function effectively; impaired impulse control; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. C.M. noted that if the Veteran were to attempt going back to work at this time, his psychiatric symptom presentation and resulting limitations would make it difficult to interact with others at work, stay on task at work, and be reliable and effective in a competitive work environment.

After careful review of the evidentiary record, resolving any doubt in the Veteran's favor, the Board finds that a TDIU is warranted. The evidence of record shows functional impairment caused by the Veteran's service-connected disabilities resulted in an inability to secure and maintain a substantially gainful occupation during the appeal period.

With respect to the economic component in Ray, the Veteran noted on his June 2019 Form 21-8940 that his income in the last 12 months was $11,000; his employer noted on the September 2019 Form 21-4192 that the Veteran earned $11,537 during the last 12 months. The poverty limit for 65 and older is $12,261 in 2019, and $12,413 in 2020. See https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html. Thus, he has met the economic component for the appeal period in 2019. In the February 2021 Form 21-4192, the employer noted that the Veteran earned $13,559 during the 12 months preceding the last date of employment of July 31, 2020. An approximate proration of the income from January to July 2021 would be $7,909. Considering the fact that the Veteran now only works 6 hours in a week, and resolving any doubt in favor of the Veteran, the Board finds that the Veteran did not earn more than $12,413 in 2020. Further, there is no indication that he has any other income. Given the above information, he has met the economic component during the appeal period.

With respect to the non-economic component in Ray, the evidence indicates that the Veteran's service-connected disabilities impact his ability to perform some physical functions. The Veteran's back and radiculopathy symptomatology may prevent him from performing occupational duties that involve strenuous physical labor, excessive walking or standing, and lifting more than 40 pounds. The Veteran's headaches can impact his ability to work in that he may experience difficulties with concentrating on tasks during headache attacks.

any doubt in favor of the Veteran, the Board finds that the Veteran did not earn more than $12,413 in 2020. Further, there is no indication that he has any other income. Given the above information, he has met the economic component during the appeal period.

With regard to the mental limitations, the examiners described the Veteran's level of occupational and social impairment as either occupational and social impairment with reduced reliability and productivity, or occupational and social impairment in most areas such as work, school, family relations, judgment, thinking or mood. The examiners consistently noted that the Veteran has difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances including work or a worklike setting. The Veteran reported during the October 2020 exam that he was unable to work because he cannot handle people anymore. The November 2021 examiner opined that the Veteran's unspecified trauma and stressor related disorder has rendered him fully unable to successfully secure and follow substantially gainful employment since at least July 2014, and that if the Veteran were to attempt going back to work at this time, his psychiatric condition would make it difficult to interact with others at work, stay on task at work, and be reliable and effective in a competitive work environment. In light of the above, the Board finds that the Veteran has significant mental limitations from his service-connected psychiatric disability.

Resolving reasonable doubt in the Veteran's favor, the Board finds he is unable to secure and maintain substantially gainful employment due to his service-connected disabilities. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Entitlement to a TDIU is warranted from the date of his claim, June 7, 2019.

Roya Bahrami

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Jake Choi, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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