Citation Nr: 1815192 Decision Date: 03/13/18 Archive Date: 03/19/18 DOCKET NO. 10-06 017 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for peripheral artery disease of the bilateral lower extremities, to include as secondary to service-connected anxiety disorder. 2. Entitlement to service connection for a disorder manifested by abdominal pain, other than service-connected duodenal ulcer. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected anxiety disorder. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Robert E. Norton, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from June 1972 to April 1973. Further, the record reflects he had additional service in the Reserves. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Veteran provided testimony at a hearing before the undersigned Veterans Law Judge (VLJ) in April 2014. A transcript of this hearing is of record. As noted when this matter was previously before the Board in November 2016, in November 2014, the Board decided and remanded some issues. In November 2016, the Board adjudicated the previously remanded issues of headaches and an anxiety disorder, and remanded the above noted claims. FINDINGS OF FACT 1. Peripheral artery disease of the bilateral lower extremities is not shown to be causally or etiologically related to any disease, injury, or incident in service, or to have been caused or aggravated by service-connected anxiety disorder. 2. A disorder manifested by abdominal pain is not shown to be causally or etiologically related to any disease, injury, or incident in service, or to have been caused or aggravated by service-connected duodenal ulcer. 3. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident in service, or to have been caused or aggravated by service-connected anxiety disorder. 4. The Veteran is service-connected for anxiety disorder (50 percent), bilateral hearing loss (30 percent), tinnitus (10 percent), and duodenal ulcer (10 percent). 5. The Veteran is not precluded from securing or following substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. Peripheral artery disease of the bilateral lower extremities was not incurred in or aggravated by the Veteran's active duty military service or develop secondary to the service-connected anxiety disorder. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 2. A disorder manifested by abdominal pain is not shown to be causally or etiologically related to any disease or injury in service or develop secondary to the service-connected duodenal ulcer. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 3. Hypertension was not incurred in or aggravated by the Veteran's active duty military service or develop secondary to the service-connected anxiety disorder. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 3.309, 3.310 (2017). 4. The criteria for a TDIU are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Hypertension, Peripheral Artery Disease of the Bilateral Lower Extremities, and a Disorder Manifested by Abdominal Pain (Other Than Duodenal Ulcer) Service Connection Claims Per his April 2014 Board hearing testimony, the Veteran has claimed that his peripheral artery disease of the bilateral lower extremities developed during service (evidenced by his legs feeling heavy and his muscles cramping in service) or alternatively developed secondary to his service-connected anxiety disorder. He further claimed he was first diagnosed with hypertension in 1996 by his private medical provider Dr. D. Madrid, who said it was due to an anxiety disorder. A. Service Connection Law Service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a), such as hypertension, and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that effective October 10, 2006, before the Veteran filed the claim, the provisions of 38 C.F.R. § 3.310 were changed to state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). B. Hypertension and Peripheral Artery Disease of the Bilateral Lower Extremities Factual Background The Veteran served on active duty from June 1972 to April 1973, with subsequent reserve service. The Veteran's service treatment records included some elevated pressure readings, but the April 1973 separation examination was negative for hypertension and showed a blood pressure reading of 110/70, as well as, normal lower extremities. Post-active duty reserve records include a July 1976 National Guard enlistment record that was negative for hypertension. In his report of medical history, he reported cramps in his legs and denied high or low blood pressure. His May 1982, January 1986, and March 1992 evaluations were negative for findings regarding the lower extremities and showed a normal blood pressure in January 1986. The March 1992 evaluation showed a blood pressure reading of 136/94. In his May 1982 and March 1992 reports of medical history, he denied cramps in his legs and high or low blood pressure. VA and private medical records generally document complaints of, or treatment for, hypertension, peripheral artery disease, and abdominal disorders; however, they generally do not contain medical etiology opinions. At most, an April 2010 VA medical record noted that the Veteran was obese and at risk for high blood pressure. As to the hypertension and peripheral artery disease claims, the Veteran underwent a VA examination in July 2015 (with a February 2016 addendum). That VA examiner found it less likely that either disorder was related to service. For the peripheral artery disease, the examiner opined that there was no documentation to support that the Veteran had peripheral vascular disease during active service; it had been diagnosed at least two decades later, and had developed secondary to his significant tobacco use. Additionally, there was no medical literature supportive of a causal link between peripheral vascular disease and anxiety. In a February 2016 addendum opinion, the VA examiner clarified that the Veteran had essential hypertension and peripheral vascular disease are common medical conditions and she saw no evidence that an anxiety disorder caused or aggravated such conditions. In January 2017, the Veteran subsequently underwent additional VA examinations. The examiner noted in-service slightly elevated blood pressures, as well as, a private medical record review showing that Dr. D. Madrid newly diagnosed hypertension in 2000. The January 2017 VA examiner opined that though the Veteran had had some elevated blood pressure readings in service, they did not validate a diagnosis of hypertension. Rather, the 1972 readings were isolated cases, most probably due to abdominal pain. Supportive of her finding was the normal separation exam and the new onset of hypertension in November 2000. Furthermore, she found no evidence to support finding that the 2000 diagnosis of essential hypertension was related to or aggravated by the Veteran's anxiety or depression. The January 2017 VA examiner further opined that for peripheral vascular disease, there was no evidence of it in service treatment records, or until 2004. She noted peripheral vascular disease risk factors included long standing tobaccoism (evidenced by multiple medical records noting a long history of smoking) and hyperlipidemia (for which the Veteran is not service-connected). The examiner noted consideration of the Veteran's lay reports of his legs feeling heavy and muscle cramps in service; however, she found post-service onset, explaining that she had considered several years of records of Dr. D. Madrid and found that the leg cramps had not been reported until November 2004. The VA examiner opined PVD was not secondary to or related to anxiety/depression disorder. The Veteran's claims were also considered by an October 2017 VA medical opinion provider, who noted in-service reports of abdominal pain and elevated blood pressure readings. The October 2017 VA medical opinion provider opined that the Veteran's peripheral artery disease was less likely related to active service, noting the April 1973 separation examination showing a normal vascular system, feet, and lower extremities. She explained that although peripheral artery disease can cause leg cramps, it is not the only cause of leg cramps, which can occur for other reversible conditions like electrolyte disturbances. Additionally, a November 2004 note on muscle cramps, showed a plan to check labs for causes of leg cramps, like potassium and sugar, with a follow up referring to intermittent claudication. The early report of leg cramps in 1976 was followed by negative complaints and negative exam findings. She noted post-service, National Guard denials of leg cramps and normal vascular findings, as well as, a November 2004 report of leg cramps in both lower extremities on and off for about 2-3 weeks. The examiner further found that it was less likely that peripheral artery disease was caused or aggravated by anxiety disorder. She explained that an anxiety disorder is not a known cause of peripheral artery disease and that she was not aware of medical literature supporting such a link. However, she noted that known risk factors for peripheral artery disease included hypertension and hyperlipidemia (for which the Veteran is not service-connected), and smoking (which the Board notes is indicated in numerous places in the medical evidence of record). The October 2017 VA examiner opined that hypertension was also less likely related to service, noting the isolated, elevated readings in 1971, but found them mostly associated with acute complaints, abdominal pain. She noted the normal separation examination and later National Guard findings, as well as, the new onset diagnosis in November 2000. Furthermore, it was less likely that hypertension was caused or aggravated beyond natural progression by anxiety disorder. She explained that it was a very common disorder and the majority of cases are essential hypertension. Risk factors included advancing age, obesity and weight gain, family history, race, reduced nephron number, high-sodium diet, excessive alcohol consumption, physical inactivity, diabetes, dyslipidemia, and personality traits and depression. Most patients have more than 1 factor. She found that despite reported early onset of mental symptoms, high blood pressure was noted in 2000 consistent with increased incidence of hypertension with advancing age and associated weight gain. She indicated consideration of other medical records, but that record review did not support a correlation between his blood pressure and anxiety. C. Abdominal Pain Disorder Factual Background In his April 1973 report of medical history for his separation from active duty, the Veteran complained of troubles of the stomach, liver, or intestine. The Board notes that the Veteran is already service-connected for a duodenal ulcer that was diagnosed in service, as such, the current claim for abdominal pain would be for a separate disorder. No other abdominal disorder was noted in service. During his hearing, the Veteran claimed that he started going to the doctor for abdominal pain in 1973 and that he had some kind of perforation in the flapper that sealed his stomach. The Veteran implied that such records would be included with those from Dyersburg Regional Medical Center; however, reviews of the records from there do not show such documents. A July 1976 post-active duty National Guard record documented that the Veteran reported having occasional gastritis. The examiner found no abdominal disorder. Subsequent National Guard examiners found no abdominal disorder, including in March 1992. At that time, the Veteran also denied having abdominal problems such as indigestion, or trouble with the stomach, liver, or intestine. Subsequent records are generally silent as to complaints of, or treatment for, abdominal complaints. One early record was a July 2009 SSA record from Jackson Clinic, Complaint of right upper quadrant abdominal pain for 6-7 months. A February 2011 VA medical record documented suspected gastroesophageal reflux disease (GERD) or peptic ulcer disease. Such records, however, generally do not document etiological opinions regarding such disorders tying them to service. The July 2015 VA examiner noted that the Veteran had reported a history of abdominal pain in service, but currently had no symptoms related to peptic ulcer (the Board notes that a peptic ulcer includes duodenal ulcer - http://www.merckmanuals.com/professional/ gastrointestinal-disorders/gastritis-and-peptic-ulcer-disease/peptic-ulcer-disease). The examiner noted that current symptoms were related to heartburn and reflux, but were less likely than not related to service. A January 2017 VA examiner determined that current radiograph did not show an ulcer. The Veteran complained of heart burn, reflux, and regurgitation. She noted that an upper gastrointestinal series indicated that the Veteran had mild GERD; there was no hiatal hernia and no definite active ulceration. The January 2017 VA examiner opined that the service treatment records validated the upper GI report. The Veteran had had a prescription in service and in 2000 was still on a proton pump inhibitor for his stomach condition. He also had some bouts of renal stones. However, current radiograph imaging demonstrated reflux, but did not show ulcer. In an April 2017 addendum, the January 2017 VA examiner clarified that condition claimed was less likely than not incurred in or caused by service. She explained that for GERD versus a duodenal ulcer diagnosis there were subjective and objective signs/symptoms that coalesce. The symptoms are overlapping and intermingled and that makes it difficult to differentiate the symptoms to each diagnosis without resorting to mere speculation. The upper GI conducted during military service did not show hiatal hernia or any gastroesophageal reflux action. The gastroesophageal reflux is a newer finding. Duodenal ulcer disease does not cause GERD. In October 2017, a VA medical opinion provider opined that it is less likely that GERD is related to the service. She explained that the in-service upper GI series did not reveal GERD and that the Veteran had denied frequent indigestion on questionnaires from 1982 and 1992. Furthermore, it was less likely that GERD was caused or aggravated by duodenal ulcer. She indicated that duodenal ulcer is not a known cause of GERD and the examiner is not aware of medical literature supporting such a link. GERD occurs with movement of gastric juice from the stomach into the esophagus. This occurs with transient lower esophageal sphincter relaxations, hypotensive lower esophageal sphincter, and anatomic disruption of the gastroesophageal junction is often associated with a hiatal hernia. The duodenum is anatomically separate from the gastroesophageal junction and the lower esophageal sphincter. EGD in 2011 showed evidence of reflux esophagitis despite normal duodenal bulb and 2nd portion of the duodenum; these are not related conditions. In view of the 2011 EGD findings of normal duodenal bulb and 2nd portion of the duodenum, it appears that the duodenal ulcer has healed with no residuals. D. Analysis The only positive opinions of record as to etiology of the claimed disorders were made by the Veteran. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether any current diagnoses of hypertension, disorder manifested by abdominal pain, or peripheral artery disease of the bilateral lower extremities are due to service or a service-connected disability, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). "Competent medical evidence" is evidence that is provided by a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). The Veteran has not demonstrated or claimed to have the medical knowledge to make such a determination. Although during his April 2014 Board hearing the Veteran claimed that his private providers, such as Dr. Merriweather, told him that his claimed disorders were associated with his anxiety disorder, such purported medical opinions from his physicians are not of record. In this regard, a lay person's account of what a doctor purportedly said is too attenuated and inherently unreliable to constitute "medical" evidence. Robinette v. Brown, 8 Vet. App. 69, 77 (1995) (Veteran's statement that his physician told him that he most probably had diabetes at time of his discharge from service was not sufficient medical evidence to establish service connection for diabetes). Furthermore, the Board notes that the October 2017 VA examiner specifically noted that she was unaware of any medical treatise supportive of such a finding. The VA examiners' respective opinions are considered probative, as they are uncontroverted by any evidence of record, apart the Veteran's own implied assertions. See Black v. Brown, 10 Vet. App. 279, 284 (1997) (in determining the weight assigned to this evidence, the Board looks at factors such as the health care provider's knowledge and skill in analyzing the medical data). Further, absent such countervailing medical evidence, the Board itself is prohibited from exercising its own independent judgment in the Veteran's favor. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board may not exercise its own independent judgment to resolve medical questions). All the VA medical opinions are consistent in finding that the claimed disorders were not caused by service or caused or aggravated by the service-connected anxiety (for the peripheral artery disease of the bilateral lower extremities and hypertension) or service-connected duodenal ulcer (for the disorder manifested by abdominal pain). Moreover, the most probative and competent medical opinions, provided by the October 2017 VA medical opinion provider, showed in-depth consideration of the evidence of record and the provider gave clear explanations as to how she reached each medical conclusion. As such, the Board finds that the most competent medical evidence is against the Veteran's claims for service connection both on a direct and secondary basis. Furthermore, the record is clear that the Veteran's hypertension developed decades after his discharge from service, such that service connection on a presumptive basis is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1991). The Veteran's claims for service connection for hypertension, peripheral artery disease of the bilateral lower extremities, and a disorder manifested by abdominal pain other than duodenal ulcer are denied. II. TDIU Claim The Veteran contends that his service-connected disabilities render him unemployable. Specifically, he claims that he retired from his job due to his service-connected anxiety. During his April 2014 Board hearing, he claimed that he was unable to work due to his service-connected anxiety and peripheral artery disease of the bilateral lower extremities (for which service connection was denied above). In a February 2010 memorandum drafted by the Veteran to his employer the State of Tennessee Department of Correction, he reported "Due to medical conditions associated with anxiety and stress...difficult to deal with the case load...performance of my duties...caused...Doctor's appointments and hospitalization...advised me on occasions that I must deal with my medical condition by reducing the amount of stress." In order to establish entitlement to TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the person to secure and follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The regulatory scheme for TDIU provides both objective and subjective criteria. Hatlestad, supra; VAOPGCPREC 75-91 (Dec. 27, 1991), 57 Fed. Reg. 2317 (1992). The objective criteria provide for a total rating when there is a single disability or a combination of disabilities that result in a 100 percent schedular evaluation. Subjective criteria provide for a TDIU when, due to service-connected disability, a Veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. The Veteran is service-connected for anxiety disorder (50 percent), bilateral hearing loss (30 percent), tinnitus (10 percent), and duodenal ulcer (10 percent), for a combined 70 percent disability rating. As such, the Veteran meets the minimum scheduler criteria for TDIU under 38 C.F.R. § 4.16(a). The Veteran has not indicated that either his tinnitus, bilateral hearing loss, or duodenal ulcer affects his employability. Rather, he claims that his anxiety symptoms are the cause of his unemployability. With respect to the Veteran's education and experience, the record reflects that he has a Master's Degree and worked as a correctional counselor for many years. As such, the relevant inquiry is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, either singularly or jointly, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. In a June 2011 statement the Veteran claimed that he had been approved for SSA benefits and supportive of that was the May 2010 VA examination and a note form Dr. Y. Rodriguez-Coneasa. As indicated in the SSA decision, Dr. Rodriguez Conesa provided an April 2011 statement that "The claimant's diagnoses were noted as peripheral vascular disease (PVD), chronic low back pain, hypertension, coronary artery disease, hyperlipidemia (HLP), and depression. Dr. Rodriguez-Conesa indicated that the claimant has been totally and permanently disabled and unable to work at any occupation since April 03, 2010." The SSA decision determined that the Veteran was unemployable, in part in consideration of the combined effect of the claimant's impairments. In contrast, a March 2011 Tennessee Department of Rehabilitation Services vocational analysis worksheet found that the Veteran could understand simple and detailed tasks, but could not make independent decisions at an executive level; he could sustain concentration with breaks and can interact with the public, supervisors, and peers. The May 2010 VA examiner found that the Veteran had held employment for several years during acute mood disturbance. The mood lability difficulty with variations in routine and low energy would likely negatively impact performance in the physical and sedentary workplace reliability and productivity. The ideal work setting would be with high level of routine tasks over which he maintains maximum control. A June 2010 SSA psychiatric review technique record found activities of daily living without significant impairment and only mild to moderate functional limitation. A July 2010 SSA record of Tennessee Disability Determination Services evaluation by Dr. L. A. Hayden found the Veteran physically capable of performing numerous types of physical work activities. An August 2011 VA examiner found occupational and social impairment due to mild or transient symptoms. A July 2015 VA examiner found occupational and social impairment with reduced reliability and productivity. The Veteran reported that his physician had encouraged him to retire due to his (nonservice-connected) heart condition and the stress experienced on his job. He stated that he has felt better emotionally since retiring from his job in corrections. After a careful review of the Veteran's claims file, the Board finds that the Veteran is not entitled to a TDIU. As noted above, the Veteran contends that only the service-connected psychiatric symptoms and nonservice-connected peripheral artery disease of the bilateral lower extremities make him unemployable. The Board does not dispute that the Veteran has had difficulties with employment due to his service-connected psychiatric symptoms. However, the record does not support finding that the Veteran is completely unemployable due to such symptoms. Indeed, the symptoms described by the Veteran are consistent with his 50 percent disability rating for anxiety. A 50 percent disability rating is indicated by occupational and social impairment with reduced reliability and productivity. The symptoms that the Veteran complains of, which are also indicative of a 50 percent disability rating, include impaired judgment and disturbances of motivation and mood. Additionally, by finding that the Veteran had reduced reliability and productivity, the July 2015 VA examiner did not find that the Veteran had total occupational impairment, which would be indicative of unemployability. The August 2011 VA examiner found only mild or transient symptoms causing occupational and social impairment. Furthermore, the note from Dr. Dr. Rodriguez Conesa was in regards to multiple service-connected and nonservice-connected disabilities, and did not provide an opinion as to only the service-connected disabilities. Similarly, the SSA decision appears to have been made based in part on the nonservice-connected disabilities. Even then, the SSA medical evaluations generally found that the Veteran could work in multiple different settings, despite his service-connected disabilities and nonservice-connected disabilities. Indeed, per the Veteran's own statements to the July 2015 VA examiner, his physician had encouraged him to retire due to both his nonservice-connected heart condition and stress. In an April 2010 VA Form 21-4192, the Veteran's employer indicated that the Veteran had retired as of April 2010. Other than his personal lay statements, the Veteran has not provided any evidence to support his claim that he would be unemployable due solely to his service-connected disabilities. The fact that a Veteran is unemployed or has difficulty finding employment is not enough to award TDIU, since a high compensation rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. In this regard, the Board notes that the Veteran has been considered to have a 70 percent disability (as an aggregate of his 50 percent for anxiety, 30 percent bilateral hearing loss, 10 percent for tinnitus, and 10 percent for duodenal ulcer). The question is whether the claimant is capable of performing the physical and mental acts required for employment, not whether the claimant could find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). As indicated above, despite some limitations imposed by his service-connected disabilities, the weight of the probative evidence is against a finding that the Veteran's service-connected disabilities would prevent him from employment. Though the Veteran has claimed that he was no longer able to perform his prior job in corrections due to stress, the record does not support showing that he is completely unemployable in other jobs. In sum, the evidence does not show that the Veteran is incapable of performing the physical and mental acts required by employment due solely to his service-connected disabilities. Though the Veteran does have difficulties due to his anxiety disorder symptoms, such difficulties are considered as part of his 50 percent rating for that disability. A TDIU is limited to consideration of service-connected disabilities that preclude the ability to work in a position commensurate with his education and experience. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim for a TDIU rating is denied. Gilbert, supra. ORDER Service connection for peripheral artery disease of the bilateral lower extremities is denied. Service connection for a disorder manifested by abdominal pain is denied. Service connection for hypertension is denied. Entitlement to a TDIU is denied. ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs