Citation Nr: 21003437 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 10-38 868 DATE: January 21, 2021 ORDER 1. Entitlement to an initial evaluation in excess of 50 percent for post-traumatic stress disorder (PTSD) prior to June 10, 2015, is denied. 2. Entitlement to a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU) prior to October 1, 2019, is denied. 3. Entitlement to referral for extraschedular consideration of TDIU from October 1, 2019 is denied. FINDINGS OF FACT 1. PTSD has not been manifested by occupational and social impairment with deficiencies in most areas. 2. The preponderance of the evidence is against a finding that the Veteran has been unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities for the period on appeal. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating for PTSD in excess of 50 percent prior to June 10, 2015 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for entitlement to a TDIU rating prior to October 1, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16(a). 3. The criteria for referral for an extraschedular TDIU rating from October 1, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16(b). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1967 to August 1969. For his meritorious service, the Veteran was awarded (among other decorations) a Combat Infantryman Badge, Vietnam Campaign Medal, and Vietnam Service Medal. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2020, the matters were remanded for consideration of new and pertinent evidence. The issue of entitlement to a rating in excess of 50 percent for PTSD from June 10, 2015 was denied and has not been appealed. Therefore, the timeframe for consideration of an increased rating for PTSD is limited to prior to June 10, 2015. There has been substantial compliance with the remand directives and the matter is again before the Board. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes the contentions of the Veteran’s representative, as detailed in a December 2020 brief incorporated with the claims file. The representative questioned the identity of a VA psychologist who examined the Veteran in 2016 and provided an addendum opinion in 2017. The representative stated that the license number listed does not belong to the stated name of the examiner, that the examiner is not presently listed as a tenant at the given address, and that the listed phone number belongs to a different psychologist. The Board has conducted a medical license search on the Department of Health's official website (https://app.hpla.doh.dc.gov/Weblookup/) and finds that the examiner is licensed and in good standing. The name of the psychologist associated with the license number as listed on the website has the same first name and middle initial as provided by the psychologist in the 2016 and 2017 examination reports, but lists a different last name. An independent search of publicly available information readily verifies that the psychologist is one person associated with both of the last names at issue, presumably due to a name change resulting from marriage. That the given address does not currently list the Veteran as a tenant more than three years after the submission of her most recent findings/opinion does not serve as a basis to disqualify the examiner’s opinion. Likewise, the provided phone number need not correspond with the physical address provided and could be associated with a professional practice that includes multiple psychologists and to which the examiner is no longer associated. This does not invalidate the examiner’s qualifications and the contention regarding identification issues does not relate to the credibility of the Board-certified psychologist. As such, the representative’s arguments are without merit. The Veteran has reported symptoms of PTSD, to include periods of depression, angry outbursts, sleep disturbances, social withdrawal and isolation, nightmares and flashbacks, low motivation, anxiety, and decreased interest. He has indicated that these symptoms interfered with his ability to work. Additionally, the Veteran has indicated that his ability to work has also been compromised by urinary urgency and incontinence resulting from his history of prostate cancer, which required a prostatectomy in 2007. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Rating Schedule is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The U.S. Court of Appeals for Veterans Claims (Court) has noted that VA amended the portion of the rating schedule dealing with mental disorders to remove the outdated references to the DSM-IV and replaced them with references to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See Golden v. Shulkin, No. 16-1208, 29 Vet. App. 221 at 224 (2018) citing 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The Court noted that VA subsequently adopted the final rule, without change, and clarified that the final rule applied to claims filed after August 4, 2014. Id. However, the Veteran's claim was received and originally certified for appeal before August 4, 2014, and, as a result, the DSM-IV must apply. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provide the following ratings for psychiatric disabilities, including PTSD: A 10 percent disability rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Under the ratings formula, a 30 percent disability rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Under the formula, a 70 percent rating is warranted where there is 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations, grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. The United States Court of Appeals for the Federal Circuit held that evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Vasquez-Claudio v. Shinseki, 713 F3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather, "serve as examples of the type and degree of symptom, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas," i.e., "the regulation . . . requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vasquez-Claudio, 713 F.3d at 11718; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission." 38 C.F.R. § 4.126(a). The Board must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination." Id. A Global Assessment of Functioning (GAF) score is a quantifiable assessment of overall functioning used by mental health clinicians that reflects an individual's "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (both citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), p. 32 (1994)). The Veteran's records include evaluations based on the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV), which includes GAF scores. The Board notes that the use of the GAF scale has been abandoned in the DSM-5 because of, among other reasons, "its conceptual lack of clarity" and "questionable psychometrics in routine practice." See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). However, as noted above, the DSM-IV is applicable in this case and was in use during portions of the appeal period when relevant medical entries of record were made. The Court has held that the use of GAF scores to assign disability ratings in instances where the DSM-5 applies, is inappropriate. See Golden v. Shulkin, 29 Vet. App. 221 (2018). However, the Court acknowledged that the Secretary did not intend the provisions of this final rule to apply to claims that were pending before the Board (certified for appeal) on or before August 4, 2014. Id. The current claim was certified for appeal to the Board prior to August 2014, therefore, the GAF scores assigned remain relevant for consideration in this appeal. GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. See Diagnostic and Statistical Manual for Mental Disorders, Fourth edition, p. 46 (1994). Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. at p. 47. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. A GAF score ranging from 31-40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). Id. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 50 percent for PTSD prior to June 10, 2015. The reasons follow. 1. Entitlement to an increased rating for PTSD, in excess of 50 percent, prior to June 10, 2015 The Veteran has reported that he first sought mental health treatment for PTSD symptoms in approximately 2007. He reported seeing a psychologist and attending group therapy sessions for about a year, before discontinuing treatment. He denied a history of other mental health treatment. The Veteran reported that he stopped working as a highway traffic control flagger in 2008 because the job was not suitable to his residual urinary symptoms. However, counseling records reflect that the Veteran stopped working in July 2009 when notes suggest that the Veteran was frustrated about the lack of hours he was getting at his job. The Veteran underwent a VA examination in February 2009 for PTSD. The Veteran displayed appropriate social skills and was noted to experience brief periods of tearfulness when describing his time in service. The Veteran reported a range of symptoms, described as mild to moderate, that have waxed and waned since his time in service, including flashbacks, nightmares, poor concentration, memory deficits, increased arousal, irritability, and some compulsive behaviors. He reported nightmares and sleep disturbances three to four times per week. The Veteran reported that his part-time work as a highway flagman was valuable because it provided him with distraction from the symptoms he experienced with too much free time. His responses were reality-based and goal-directed in nature. On mental status examination, the Veteran was found to have adequate long-term memory with moderate dysfunction in short-term memory. He had adequate judgment and insight and denied suicidal ideation. He did not appear to be responding to internal stimuli, He reported that he is able to complete activities of daily living such as cooking cleaning, grooming, operating a motor vehicle, and basic hygiene independently on a daily basis. He also reported that his PTSD symptoms did not present a significant impediment to his ability to work at the time. He was diagnosed with PTSD and provided a GAF score of 55. Periodic counseling records from 2008 to 2010 indicate the Veteran to experience depressive symptoms resulting from multiple factors, including unemployment, finances, and family relations. Notes also indicate feelings of frustration, low motivation, sleep problems, and difficulty with relationships. The Veteran worked in group therapy to share feelings, manage stress, improve time management, and focus on accomplishing tasks. In March 2009, the Veteran was assessed with a GAF of 55. The following month he was reported to be doing relatively well, despite some continued difficulties with issues noted above. In May 2009, he reported traveling to Las Vegas for a trip and was noted to be dealing with life more positively. In June 2010, a marriage and family therapist from the Veteran’s counseling service provided an assessment regarding the Veteran’s PTSD, cosigned by a marriage and family therapist with a doctorate in Ministry. The report indicated that the Veteran symptoms include unpredictable outbursts of rage followed by periods of depression, flashbacks to events in Vietnam, sleep interruption and nightmares, social withdrawal, and isolation from virtually all social relationships. The private examiner stated that the Veteran is now unable to work and will remain unemployed, but did not address DSM criteria or provide a contemporaneous mental status examination. The Veteran was assessed a GAF score of 39. The Veteran again underwent a VA examination in June 2011. The Veteran generally reported a continuation of the symptoms discussed herein with occasional angry outbursts, but he denied experiencing nightmares, flashbacks, and behavioral avoidance. He reported a good marriage and an improvement in his strained relationship with his adult daughters, and he was assessed with mild social impairment due to his limited socializing. On mental status examination, the Veteran exhibited appropriate behavior, no impairment in thought process or communication, a linear and goal-directed thought process, and no delusions/hallucinations. The examiner wrote that the Veteran’s PTSD does not impair his activities of daily living. The examiner stated that the Veteran’s PTSD had not progressed or changed in a clinically significant manner since his prior VA examination in February 2009. The Veteran was again assessed with a GAF score of 55. The Veteran did not engage in regular mental health treatment after 2010 and has not been prescribed psychotropic medication. VA treatment notes from March 2014 indicate that the Veteran acknowledged his prior history of group therapy sessions but stated that he did not wish to re-engage in mental health treatment. The Veteran stated that while he does feel down at times, his wife does not let him stay that way. He denied suicidal ideation and any past history of suicide attempts. The Veteran next underwent a VA examination in June 2015, marking the end of the period on appeal. However, the examination reflects the Veteran’s functioning prior to the examination and, thus, is appropriate for consideration herein. The Veteran continued to report an improved but distant relationship with his adult daughters. He stated that he struggles with low motivation and feelings of being overwhelmed. He described a moderate level of social impairment relating to his continued tendencies for social isolation. The Veteran reported that he primarily spends his time doing chores around the house, such as washing, laundry, and yardwork, but that he also has a few activities he enjoys, including riding his scooter, going to the beach, and traveling. The Veteran reported that he was able to fully and independently complete his activities of daily living. The Veteran’s behavior was appropriate and he was described as friendly and conversational. He was fully alert and oriented with a logical and goal-directed thought process, and intact judgment. In the June 2015 VA examination report, when asked which of the following best summarized the Veteran’s level of occupational and social impairment, the examiner checked occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication, which is the level of severity described under a 10 percent rating. While the adjudicator makes the determination of what evaluation is warranted for the service-connected PTSD, the examiner’s conclusion that the Veteran’s PTSD was summarized best by the criteria described under the 10 percent rating is evidence against a finding that the Veteran’s psychiatric disorder caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood to warrant a 70 percent rating or higher. The findings of the June 2015 VA examiner are also generally consistent with the evidence prior to June 2015, which does not suggest a level of disability warranting an increased rating in excess of 50 percent. Specifically, the preponderance of the evidence is against a finding that the Veteran’s symptoms demonstrate the severity of symptoms described for a 70 percent rating, including 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships. For example, the Veteran’s mental status examinations have been generally unremarkable, indicating no impairment in thought process or communication, a linear and goal-directed thought process, no delusions/hallucinations, and intact judgment. The Veteran has routinely denied suicidal ideation and has indicated that he is fully independent in activities of daily living. During the relevant period, the Veteran reported that his PTSD symptoms did not prevent him from working and he reported that he stopped working for reasons unrelated to his PTSD symptoms. Despite some social dysfunction and isolation, the Veteran has reported having friends, a good marriage, and an improved relationship with his daughters. This is evidence against deficiencies in family relations and the inability to establish and maintain effective relationships. The Veteran performs chores, rides his scooter, and enjoys traveling and going to the beach. While the probative value of GAF scores is inherently somewhat limited as discussed above, the record does not demonstrate more than moderate symptomology, consistent with the recurrent assessment of a GAF score of 55. The findings noted above regarding the Veteran’s functional abilities is not consistent with private assessment from 2010 that indicated that the Veteran is unable to work with a GAF score of 39, which would indicate some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. As stated, the Veteran has had relatively normal findings on mental status examination and has maintained independence in activities of daily living with no more than moderate social dysfunction, which includes reports of friends, a good marriage, the ability to travel and descriptions by professionals of being friendly and conversational on examination. He has not receive ongoing routine treatment, had no history of inpatient psychiatric hospitalization, and has not required psychotropic medication. The Veteran also worked up to 2009 and indicated that he stopped due to limitations unrelated to his PTSD, with a preponderance of the evidence indicating generally stable functioning thereafter. In 2017, a VA psychologist was asked to opine regarding the conflicting evidence between VA records and the more severe findings indicated in the 2010 private assessment by the marriage and family therapist. The psychologist stated that the 2010 assessment is given less weight than the prior VA examinations because DSM criteria were not addressed; the evaluation was conducted by a marriage and family therapist with a doctorate in Ministry and not a psychologist; and the reported GAF score of 39 was not consistent with the Veteran’s reports of daily functioning and work history. This opinion was provided by a medical expert who was able to review the evidence of record and provided a rationale consistent with the longitudinal evidence of record regarding the Veteran’s PTSD. Accordingly, the Board has determined the findings of the VA examiners to be more probative than the 2010 private assessment of the marriage and family therapist. Therefore, the Board finds that the Veteran’s PTSD symptoms are most closely approximated by the assigned 50 percent disability rating. Importantly, as described in detail herein, the preponderance of the evidence is against the Veteran showing occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood; nor are her PTSD symptoms of similar severity, frequency, and duration to warrant an increased 70 percent disability rating. As the Board has found that the Veteran’s disability picture did not rise to the level of severity of the 70 percent rating, it follows that the Board finds that the disability picture did not rise to the level of severity of the 100 percent rating prior to June 10, 2015. For all the reasons stated herein, the evidence does not support the award of an increased rating in excess of 50 percent for PTSD prior to June 10, 2015. As the preponderance of the evidence is against the claim for increased rating, the benefit of the doubt doctrine is not for application, and the Veteran’s claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. TDIU Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation because of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, the disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and enough additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). As a preliminary matter, the Veteran’s service-connected disabilities do not meet the percentage requirements for a schedular TDIU under 38 C.F.R. § 4.16(a) for the entire period on appeal. The Veteran is currently service-connected for PTSD at 50 percent; residuals of prostate cancer at 20 percent; erectile dysfunction associated with residuals of prostate cancer, rated at zero percent; and scars association with residuals of prostate cancer, rated at zero percent. This equates to a current combined rating of 60 percent. However, the Veteran previously had a 70 percent combined rating, relating to a 40 percent rating for residuals of prostate cancer, from June 1, 2009 to September 30, 2019, which did qualify for schedular TDIU consideration. Prior to June 1, 2009, the Veteran had a 100 percent combined rating due to a 100 percent rating for residuals from prostate cancer beginning November 5, 2007, which precludes TDIU consideration. Therefore, the period on appeal for schedular TDIU consideration is June 1, 2009 to September 30, 2019. When the percentage requirements are not met, entitlement to a TDIU rating may be considered on an extraschedular basis when the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular TDIU rating in the first instance. See Bowling v. Principi, 15 Vet. App. 1 (2001). However, it may determine whether the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities, and then refer the issue to the Director of the Compensation Service, for a determination in the first instance as to whether the Veteran is entitled to a TDIU rating on an extraschedular basis under 38 C.F.R. § 4.16(b). Accordingly, from October 1, 2019, the Board will analyze whether the evidence of record demonstrates the need for a referral to the Director of the Compensation Service for extraschedular consideration. "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16. In determining whether a veteran can secure and follow a substantially gainful occupation, the United States Court of Appeals for Veterans Claims (Court) in Ray v. Wilkie directed the Board to consider the following factors: (1) the veteran's history, education, skill, and training; (2) whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities required by the occupation at issue; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue. 31 Vet. App. 58, 73 (2019). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The responsibility for making the ultimate TDIU determination is placed on the adjudicator and not a medical examiner. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). A medical examiner's role is limited to describing the effects of disability upon the person's ordinary activity. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran is competent to testify as to facts he personally observed or described; this includes recalling what he personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against a finding that the Veteran has been precluded from securing and following substantially gainful employment for the duration of the period on appeal. The reasons follow. 2. Entitlement to TDIU prior to October 1, 2019, and to referral for extraschedular consideration of TDIU from October 1, 2019 For purposes of considering the Veteran’s TDIU claim, the above findings relating to the Veteran’s PTSD severity prior to June 10, 2015 are incorporated herein. The relevant period for consideration of TDIU began with a rating decision that reduced the Veteran’s rating for residuals of prostate cancer from 100 percent to 40 percent in June 2009 following his 2007 radical prostatectomy. This reduction was based on an October 2008 VA examination indicating that the Veteran was voiding 10 to 12 times during the day and two to six times at night, but was not experiencing urinary incontinence, did not required the use of absorptive pads, and had no renal dysfunction. Therapy treatment records indicate that the Veteran stopped working in July 2009 and he reported that this was due to a lack of bathroom access at his work sites as a highway flagger. The treatment records since that time reflect only periodic treatment without significant exacerbations or need for inpatient treatment. Despite some continued symptoms of urinary urgency, the Veteran’s reporting does not suggest other significant physical limitations from residuals of his prostate cancer that would preclude the Veteran from substantially gainful employment. For example, in 2015, the Veteran reported that he spends his time doing chores around the house, such as washing, laundry, and yardwork. He stated that he enjoys riding his scooter, going to the beach and traveling. He was noted to be fully independent in activities of daily living. The Veteran underwent a VA examination relating to residuals from prostate cancer, including erectile dysfunction, retrograde ejaculation, and stress incontinence, in September 2016. When asked what the impact of these problems were on the Veteran’s ability to work, the examiner stated that the impact of the prostate cancer on the Veteran’s ability to work is that, due to stress incontinence, he should have ready access to bathroom facilities. The Veteran also underwent a VA examination for PTSD in September 2016 and was diagnosed with mild PTSD. Upon review of the claims file and contemporaneous examination of the Veteran, his primary symptoms were identified as depressed mood, anxiety, suspiciousness, and disturbances of motivation and mood. Following evaluation, the examiner concluded that the Veteran did not need to seek follow-up treatment for his disability at that time, and did not pose a threat of danger or injury to himself or others. The Veteran was described as talkative and friendly, and he denied seeking or following any mental health treatment. Rather, the examiner concluded that although a mental condition was formally diagnosed, the Veteran’s symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. Such is commensurate with the criteria for a noncompensable disability rating. In a July 2017 addendum opinion, the examiner similarly concluded that although the Veteran’s symptoms had worsened upon his retirement, they had since “significantly subsided.” As a result, the evaluator again concluded that although a mental condition was formally diagnosed, the Veteran’s symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. A VA practitioner submitted a DBQ concerning residuals from the Veteran’s prostate cancer in June 2017. After reviewing the evidence of record, the practitioner opined that, due to urinary leakage with heavy work, it would be advisable for the Veteran to consider more sedentary work that does not entail heavy lifting. The practitioner stated that, although the Veteran’s prior work as a highway flagger did not involve heavy lifting, the lack of close bathroom facilities made the position untenable to due urinary frequency. The practitioner stated that the Veteran’s erectile dysfunction had no occupational impact. A July 2017 DBQ opinion also notes that the Veteran’s PTSD had not precluded him from sustaining a stable work history for approximately 30 years, including the ability to maintain relationships with coworkers, perform daily responsibilities, and sustain attention to perform necessary tasks. No related hospitalizations were reported, and the Veteran was not prescribed any medication to assist with managing his symptoms, and denied participation in any optional mental health services. Thus, the examiner noted that the Veteran presented with symptoms that were mild and transient, but could impact work efficiency in particularly stressful situations. The Veteran underwent another VA examination relating to his prostate residuals in April 2018, which served as the basis for the reduction of the Veteran’s disability rating from 40 percent to 20 percent. The Veteran reported some urinary leakage, but not so severe that he normally needs to use an absorbent pad. The Veteran reported daytime voiding every one to two hours and nighttime voiding 3 to 4 times. The examiner stated that the Veteran would be able to do a sedentary job that required only minimal physical exertion, provided that he had ready access to a bathroom because of his urinary frequency. Otherwise, the examiner found that there would be no restriction on his employability to due to his history of prostate cancer. Thereafter, the record indicates only routine treatment with generally stable functioning, and without significant exacerbations of the Veteran’s service-connected disabilities. The Board notes that the April 2018 VA examiner did not define the term sedentary, and the term is also not defined by VA regulations for TDIU. Rather, the meaning is to be determined on a case-by-case asis, including how the concept of sedentary work figures into the Veteran’s overall disability picture and vocational history. See Withers v. Wilkie, 30 Vet. App. 139 (2018). In this instance, the Board finds it appropriate to use a common definition of sedentary work as work that most often allows sitting and does not require exertion for lifting, carrying, pushing, or pulling of more than ten pounds. Medical sources of record do not suggest that the Veteran is limited beyond these restrictions and the Veteran’s own reporting of his activities of daily living support the notion that he is more than capable of performing such work. The Veteran’s physical limitations can be accommodated by ready access to a bathroom and a restriction from heavy lifting. This is supported by the Veteran reporting that he spends most of his time performing household chores and yardwork and enjoys traveling and riding a scooter. Such findings do not indicate that the Veteran is physically restricted from working and medical examiners have indicated that the Veteran is still able to physically fulfill the requirements of employment. The preponderance of the evidence is against occupational limitations relating to service-connected erectile dysfunction or scars. Accordingly, the weight of the evidence suggests that the Veteran is physically capable of performing substantially gainful employment. Regarding the Veteran’s education, training, skills, and work history, the Veteran reported that he retired from a 30-year career at Verizon in 2003 because he was eligible for a buyout. He has indicated that he has a high school education. A Verizon representative confirmed in 2016 that the Veteran received a buy-out as part of a work force reduction in 2003 and wrote “N/A,” which is not applicable to the question asking if the Veteran required any accommodations relating to a disability. Thereafter the Veteran reported working as a highway traffic control flagger but stopped in 2009 because the job was not suitable to his residual urinary symptoms, as discussed herein. At the February 2009 VA PTSD examination, the Veteran reported that he was a highway fireman working part time and that the job was not difficult, but that he did not find the job enjoyable any longer. The Veteran has also reported that his past employment was valuable because it provided him with distraction from the symptoms he experienced with too much free time. The Board finds that the Veteran’s long and consistent job history prior to 2009 demonstrates a capacity for learning, training, adaptation, and working effectively with others that are not hindered by his service-connected disabilities and which would allow for transition to a different type of employment. As to the Veteran’s mental ability to perform substantially gainful employment, the weight of the evidence does not show that the Veteran has mental limitations that would preclude him from performing substantially gainful employment. For example, VA practitioners in 2016 and 2017 opined that the Veteran’s symptoms were not severe enough either to interfere with occupational and social functioning or required continuous medication. With deference to the 2017 practitioner who indicated that the Veteran’s symptoms can manifest in stressful situations, it appears that the Veteran’s PTSD can be accommodated by restricting the Veteran from high-stress work. As noted, the Veteran has recorded primarily unremarkable findings on mental status examinations during the relevant period, which includes no impairment in thought process or communication, a linear and goal-directed thought process, no delusions/hallucinations, and intact judgment. Despite some reports of social isolation, the Veteran has maintained independence in activities of daily living with no more than moderate social dysfunction, which includes reports of friends, a good marriage, the ability to travel, and descriptions of being friendly and conversational on examination. Thus, the preponderance of the evidence is against a finding that the Veteran has mental limitations that would preclude him from substantially gainful employment. Based on the above assessment of the Veteran’s physical and mental abilities with consideration of his education, training, skills, and work history, the Board finds that the Veteran is capable of full-time work that would result in income at the level of substantially gainful employment. For example, there are jobs that can be performed from home, such as a telemarketer, where the employee makes calls and reads a script, which does not require extensive training or experience, would be low-stress, would be repetitive, have structure, would not necessarily involve new tasks or novel concepts, would require minimal exertional activity, and would have easy access to the restroom, and the Veteran could take breaks as needed. Similarly, the Veteran appears capable of performing certain cashier positions, or work as a library or museum attendant, positions that would facilitate the Veteran’s need for bathroom access without requiring significant physical exertion or exposure to high-stress scenarios. This is evidence against a finding that the Veteran is precluded from all forms of substantially gainful employment. For all the reasons described above, the Board finds that the preponderance of the evidence is against a finding that Veteran is precluded from all forms of substantially gainful employment and, therefore, is not entitled to a TDIU rating or referral for extraschedular consideration of TDIU during the appeal period. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, entitlement to a TDIU rating or referral for extraschedular consideration of TDIU is not warranted. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Wonderling, 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.