Citation Nr: 1828658 Decision Date: 05/11/18 Archive Date: 05/18/18 DOCKET NO. 13-35 551 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). 3. Entitlement to an evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) from August 8, 2014. 4. Entitlement to a total disability rating due to individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney at Law ATTORNEY FOR THE BOARD W. R. Stephens, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1967 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In an October 2015 correspondence from his representative, the Veteran requested a hearing before a Veterans Law Judge. However, in a subsequent correspondence received by VA in June 2016, the Veteran withdrew such hearing request. As such, there is no outstanding hearing request. 38 C.F.R. § 20.704 (e)(2017). The Board remanded these matters in January 2013, December 2015 and August 2016 for additional development. Subsequent to the Board's August 2016 Remand, an August 2017 rating decision granted an increased rating of 70 percent for PTSD, effective August 8, 2014. The Board notes that entitlement to a TDIU was denied in an April 2017 rating decision. Pursuant to the Court's holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board has determined that entitlement to a TDIU has been raised by the record and has considered the TDIU claim as part of the pending increased rating claim. FINDINGS OF FACT 1. Obstructive sleep apnea did not manifest in service and is unrelated to service. 2. Obstructive sleep apnea is not caused or aggravated by a service-connected disease or injury. 3. For the entire period on appeal, the Veteran's PTSD is manifested by symptoms such as impaired impulse control; difficulty adapting to stressful circumstances; neglect of personal appearance and hygiene; and hypervigilance; resulting in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but less than total occupational and social impairment. 4. The Veteran is not rendered unable to engage in substantially gainful employment by reason of his service-connected disabilities. CONCLUSIONS OF LAW 1. Obstructive sleep apnea was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303 (2017). 2. Obstructive sleep apnea is not proximately due to, the result of, or aggravated by a service connected disease or injury. 38 C.F.R. §§ 3.102, 3.310 (2017). 3. The criteria for an initial evaluation of 70 percent for PTSD, but no higher, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2017). 4. The criteria for an evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2017). 5. The criteria for entitlement to a TDIU are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Service Connection for Sleep Apnea Veterans are entitled to compensation if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service -the so-called 'nexus' requirement." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Obstructive sleep apnea is not identified as a "chronic" disease under 38 U.S.C. § 1101 and 38 C.F.R. § 3.309(a). As a result, the provisions of 38 C.F.R. § 3.303 (b) are not applicable. Service connection is warranted on a secondary basis for "disability which is proximately due to or the result of a service-connected disease or injury." 38 C.F.R. § 3.310 (a). Secondary service connection is also warranted for "[a]ny increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease." 38 C.F.R. § 3.310 (b). The Board notes that 38 C.F.R. § 3.310 was amended, effective October 10, 2006. Under the revised § 3.310(b) (the existing provision at 38 C.F.R. § 3.310 (b) was moved to sub-section (c)), any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. With respect to direct service connection, a review of service treatment records shows no relevant complaints, objective findings, treatment, diagnosis, or any other manifestations of a sleep disorder. The Veteran's June 1969 separation examination revealed normal nose, sinuses, mouth and throat upon physical examination. In a June 1969 report of medical history upon separation, the Veteran specifically denied frequent trouble sleeping or any relevant symptoms. At a June 2017 VA examination, a diagnosis of obstructive sleep apnea was confirmed. The Veteran had been diagnosed in 2011. The VA examiner concluded that the Veteran's sleep apnea was less likely than not related to his military service. The examiner's rationale cited service treatment records and medical records. The Board accepts the June 2017 VA medical opinion that the Veteran's obstructive sleep apnea is less likely than not related to his military service as highly probative medical evidence on this point. The examiner rendered her opinion after thoroughly reviewing the claims file and relevant medical records. The examiner noted the Veteran's pertinent history and provided a reasoned analysis of the case. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994) (the probative value of a physician's opinion depends in part on the reasoning employed by the physician and whether or not (or the extent to which) he reviewed prior clinical records and other evidence). To the extent that the Veteran has asserted his obstructive sleep apnea is directly related to his military service, the Board finds that the probative value of the general lay assertions are outweighed by the medical evidence of record which does not show any pathology, disease, residuals of injury or diagnoses of obstructive sleep apnea in service or for many years after discharge. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011) (noting impropriety of the Board categorically discounting lay testimony and requiring the Board to determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence is competent); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As previously noted, the evidence of record suggests that obstructive sleep apnea was not identified until 2011. Nothing at the time of initial testing suggested a history relating back to service. To the extent that there is an assertion that he had symptoms of apnea during service, such remote statements are inconsistent with the service records and are not credible. Here, there is no reliable evidence that he had symptoms of apnea during service or in proximity to service. To the extent that the Veteran has asserted a continuity since service, the Board again notes that the provisions of 38 C.F.R. § 3.303 (b) do not apply in this instance. The medical evidence of record is afforded greater probative value than the more general lay assertions of the Veteran. See Kahana, supra; see also Jandreau, supra. In sum, there is no reliable evidence linking the Veteran's obstructive sleep apnea to service. The contemporaneous records establish that the relevant systems were normal at separation. The more probative evidence establishes that he did not have sleep apnea during service and that his current disorder is not related to military service. The evidence establishes that the remote onset of obstructive sleep apnea is unrelated to service. For all of these reasons, service connection on a direct basis is not warranted for obstructive sleep apnea. With respect to the Veteran's secondary service connection claim, the Board will now address whether the Veteran's obstructive sleep apnea was caused or aggravated beyond its natural progression by his service-connected PTSD. In a March 2016 statement, the Veteran asserts that his service-connected PTSD is responsible for his sleep apnea. The Veteran reported that when he did not have nightmares, he did not stop breathing in his sleep, or experience apnea. The Veteran also submitted a statement from his wife, echoing the belief that his PTSD caused his sleep apnea. In support of this contention, the Veteran submitted medical literature documenting a study which found that "sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Administration beneficiaries. This association suggests that patients with psychiatric disorders and coincident symptoms suggesting sleep-disordered breathing should be evaluated for sleep apnea." However, the study emphasized that the disorders were comorbid with no analysis of causation or aggravation. Comorbidity does not equate to causation. Comorbid is defined as pertaining to a disease or other pathologic process that occurs simultaneously with another. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 399 (31st ed. 2007). Pursuant to the Veteran's March 2016 assertion, the Board ordered a VA examination and medical opinion in its August 2016 Remand. The June 2017 VA medical examiner concluded that the Veteran's obstructive sleep apnea was less likely than not caused or aggravated by his service-connected PTSD. The examiner explained: "This type of causativeness cannot be explained with known neuroanatomic principles and with the available objective. [Obstructive sleep apnea] is caused by a physical/mechanical obstruction in the airway and is not a result of a psychiatric condition. A psychiatric condition cannot physically block a person's airway and cause the airway to block." The examiner cited a treatise by the National Institutes of Health. The Board accepts the June 2017 VA medical opinion that the Veteran's obstructive sleep apnea is less likely than not related to his service-connected PTSD as highly probative medical evidence on this point. The Board notes that the examiner rendered her opinion after thoroughly reviewing the claims file and relevant medical records. The examiner noted the Veteran's pertinent history and provided a reasoned analysis of the case. See Hernandez-Toyens, supra; Gabrielson, supra. The Board finds that the examiner's opinion, specific to this Veteran's medical history and rendered after a review of the Veteran's medical history, is more probative than the medical literature submitted by the Veteran which analyzed a study that was not specific to the Veteran's circumstances. In short, the VA examiner provided an opinion tailored to the factual basis at hand. The medical literature submitted by the Veteran pertained to a study that was not based upon the Veteran's own medical history. The Board again acknowledges that the Veteran is competent, even as a layperson, to attest to factual matters of which he has first-hand knowledge, e.g., an injury during his active military service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau, supra. However, as a layperson, it is not shown that the Veteran possesses the medical expertise to provide a medical opinion linking his currently diagnosed obstructive sleep apnea to his service-connected PTSD. The only medical opinion of record addressing the claimed relationship is negative. No competent medical opinions linking his obstructive sleep apnea and PTSD have been presented. The VA examiner considered the Veteran's lay assertions, but ultimately found that the Veteran's obstructive sleep apnea was not caused by or aggravated by his service-connected PTSD. The Board finds that the Veteran's lay statements are outweighed by the VA examiner's medical opinion as it was based on consideration of the Veteran's contentions, reviews of medical records, and medical expertise. The Board finds that the preponderance of the evidence is against a finding that the Veteran's currently diagnosed obstructive sleep apnea is directly related to service, or in the alternative, secondary to service-connected PTSD, and the claim must be denied. III. Increased Evaluation PTSD Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of a veteran. 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Board has determined that a uniform rating is appropriate throughout the period on appeal. The Veteran's PTSD is currently assigned an initial 50 percent rating under Diagnostic Code 9411, effective May 31, 2011. A rating of 70 percent has been assigned effective August 8, 2014. The Veteran has challenged the initial rating and subsequent 70 percent rating. Diagnostic Code 9411 pertains specifically to the primary diagnosed disability in the Veteran's case (PTSD). In any event, with the exception of eating disorders, all mental disorders including PTSD are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Moreover, the Veteran has not requested that another diagnostic code be used. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9411. The criteria for a 50 percent rating are as follows: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are as follows: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. The criteria for a 100 percent rating are as follows: 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Id. The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). The RO originally certified the Veteran's appeal to the Board in January 2015. As a result, the Board will evaluate in a manner most favorable to the Veteran. Factual Background At an April 2012 VA examination, the Veteran reported intrusive thoughts, emotional detachment, mood dysphoria, restricted range of emotion, difficulty talking about Vietnam, irritability, and hypervigilance resulting in checking the doors and windows every night. A GAF score of 60 was assigned. Additional symptoms included recurrent and distressing recollections, avoidance efforts, markedly diminished interest or participation in significant activities, sleep impairment, outbursts of anger, depressed mood, anxiety, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. The examiner concluded that the Veteran's PTSD symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. At a January 2017 VA examination, the Veteran reported that he had been married for 43 years. He has three grown daughters and a grandchild. He described family relations as good. He associated with two brothers-in-law and has frequent contact with his four siblings. He reported many of the same symptoms as at his April 2012 examination, including depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. The examiner concluded that the Veteran's PTSD symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner opined that since the April 2012 VA examination, the Veteran's "mental health condition has not increased in frequency, severity or duration." In a March 2016 statement, the Veteran reported multiple panic attacks per week, constant depression, hypervigilance, neglect of personal hygiene and appearance, irritability and "rage outbursts," homicidal ideation, and other symptoms. He reported that he has experienced these since at least May 2011. In essence, the Veteran states that his PTSD symptoms have remained constant throughout the period on appeal. An accompanying statement from his wife supports the Veteran's statement. The Board has reviewed additional medical and lay evidence associated with the claims file. Analysis As noted, the Veteran has an initial 50 percent evaluation dating back to May 11, 2011, and a 70 percent rating from August 8, 2014. After a review of the medical and lay evidence of record, a 70 percent evaluation is warranted for the entire time period on appeal. The evidence suggests that the Veteran's symptomatology has more nearly approximated occupational and social impairment associated with a 70 percent evaluation for the entire period on appeal. In other words, the Board finds that an initial evaluation of 70 percent is warranted, but that the preponderance of the evidence is against an evaluation in excess of 70 percent during this period. Neither the lay nor the medical evidence of record more nearly approximates the frequency, severity, or duration of psychiatric symptoms required for a 100 percent disability evaluation, nor does it demonstrate total social or occupational impairment. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. The Board has considered the VA treatment records, including all VA examination reports and lay statements regarding the impact of the Veteran's PTSD on his occupational and social impairment. During the entire period, the Veteran reported recurrent and distressing recollections and dreams of the events; difficulty interacting with others resulting in isolative behavior; diminished interest in activities; depressed mood; disturbances of mood and motivation; sleep impairment; hypervigilance; irritability; and impaired impulse control, among other symptoms. It is documented that the Veteran has struggled with many social interactions. The Board finds that the degree to which the Veteran's PTSD inhibits his social relationships is consistent with the criteria of a 70 percent evaluation. The record is clear that the Veteran is not unable to establish and maintain relationships, as he maintains good relations with family members. Most notable are the Veteran's symptoms of irritability, impaired impulse control, and reported homicidal ideation. As an initial matter, the Board recognizes the severity of the Veteran's assertions in the March 2016 statement regarding his "feeling like [he] wanted to kill someone." The Board does not take this statement lightly. However, a review of this statement and the medical evidence of record does not indicate that the Veteran is a persistent danger to other people, that he attempted any act, or that any physical or mental health intervention was initiated. Certainly this statement is concerning, but the Board finds that the degree to which the Veteran experiences irritability and impaired impulse control, this is accounted for by the 70 percent evaluation. While there is no indication that the Veteran's irritability has resulted in violence or in a persistent danger of hurting others, the Board finds that the Veteran's symptoms result in a significant deficiency in his ability to maintain and establish relationships and handle stressful circumstances. Considering the Veteran's symptoms as a whole for the entire period on appeal, the evidence suggests that the resulting social and occupational impairment more closely approximates a 70 percent evaluation. Throughout the entire period, there was no indication of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger in hurting self or others, inability to perform activities of daily living, disorientation of time or place, or memory loss for names of close relatives. Furthermore, the objective medical conclusions of the VA examiners with respect to the severity of the Veteran's occupational and social impairment, while not determinative, are not consistent with total occupational and social impairment. Thus, the Board finds that for this period the Veteran does not have total occupational and social impairment. He does have some deficiencies in several areas, but the greater weight of evidence demonstrates that it is to a degree that is contemplated by the 70 percent rating assigned herein. Furthermore, even resolving any reasonable doubt in the Veteran's favor, the Board finds that he does not meet the requirements for an evaluation greater than the now assigned initial 70 percent schedular rating. To the extent that the Veteran has any of the criteria for a 100 percent rating, see Mauerhan, 16 Vet. App. at 442, the Board concludes that his overall level of disability does not exceed the criteria for a 70 percent rating. IV. TDIU Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extra-schedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities. 38 C.F.R. § 4.16 (b). 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 education, special training, and previous work experience, 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; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Currently, the Veteran is in receipt of a 70 percent evaluation for posttraumatic stress disorder (PTSD) and a 60 percent evaluation for residuals of prostate cancer. As a result, the Veteran meets the criteria for a schedular TDIU rating per 38 C.F.R. § 4.16 (a). In a November 2016 VA Form 21-8940 Application for TDIU, the Veteran indicated that he was last employed full-time in November 2014 as a lineman at an energy company. The Veteran indicated that he became too disabled to work at that time as a result of both service-connected disabilities. The Veteran indicated that he completed 2 years of college. At the Veteran's most recent VA prostate examination in January 2017, the examiner reported that the Veteran's residuals had no impact on his ability to work. The residuals were voiding dysfunction requiring the use of absorbent material which must be changed more than 4 times per day, voiding dysfunction which required depends diapers on the weekend, and erectile dysfunction. At the Veteran's January 2017 VA PTSD examination, the examiner concluded that the Veteran was capable of sedentary employment with routine and consistent job demands. "The record does not provide evidence of severe and persistent [mental health] symptoms where functional impairment restricting him from working in any capacity would be evident." Based on a review of the record, including written statements by the Veteran and his wife, the Board finds that the Veteran's service-connected disabilities, either individually or collectively, do not render him unable to secure and follow a substantially gainful occupation. In this regard, VA examination indicates that the Veteran's residuals of prostate cancer have either no functional impact or limited impact on his employability. While the Veteran's service-connected PTSD certainly has an impact on his ability to work, there is no indication that it renders him unable to maintain a sedentary job with routine tasks. The Veteran's service-connected disabilities do not limit him to the extent that he could not engage in sedentary or semi-sedentary employment, or prevent him from interacting with coworkers or supervisors in a limited capacity. While the Veteran has social impairment, the record does not indicate that he has an inability to establish and maintain effective relationships, despite his 70 percent evaluation. These conclusions were based on interviews of the Veteran, review of the claims file and examination of the Veteran. While the Veteran does not have education beyond two years of college, this would not prevent him from obtaining a wide variety of occupations consistent with is long career of work with an energy company. There is no evidence that the Veteran is unable to leave the home, drive a vehicle, and use ordinary administrative tools such as a keyboard, touch screen or telephone in a work environment with limited interpersonal contact. Additionally, the Board has considered the Veteran's lay assertions that he is unemployable due to his service-connected disabilities. However, the Board finds the objective medical evidence to be more probative than his lay assertions in determining that his service-connected disabilities do not render the Veteran unable to secure or follow a substantially gainful occupation. See Jandreau, supra. Viewing the combined effects of the Veteran's service-connected disabilities, the preponderance of the evidence shows that the Veteran is capable of sedentary or semi-sedentary work, and is capable of interacting with others in a limited fashion, to include coworkers and supervisors. The Board finds that given the Veteran's education, experience, and functional limitations specific to his service-connected disabilities, he is capable of successfully maintaining a variety of occupations. See Van Hoose, 4 Vet. App. at 363. The Board acknowledges the requirement that an occupation must be substantially gainful, in that a veteran should be able to earn income that "that exceeds the poverty threshold for one person." Faust v. West, 13 Vet.App. 342, 356 (2000); see also 38 C.F.R. § 4.16 (a). The Board finds that the Veteran's educational and professional experience would enable him to earn income greater than the poverty level. The controlling question is whether the Veteran is capable of such employment, not whether he has actually engaged in such employment. In sum, the more credible and probative evidence establishes that the Veteran is not precluded from employment and is functionally able to perform tasks required in sedentary and semi-sedentary employment with relatively routine tasks. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). ORDER Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial evaluation of 70 percent for posttraumatic stress disorder (PTSD) is granted. Entitlement to an evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating due to individual unemployability due to service-connected disabilities (TDIU) is denied. ____________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs