Citation Nr: 21062375 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 19-01 263 DATE: October 7, 2021 ORDER 1. Entitlement to an evaluation in excess of 50 percent prior to December 10, 2018 for posttraumatic stress disorder and major depressive disorder with alcohol use disorder (PTSD) is denied. 2. Entitlement to a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Prior to December 10, 2018, PTSD was not manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. The preponderance of the evidence is against a finding that Veteran is precluded from securing or following a substantially gainful occupation due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating in excess of 50 percent for PTSD prior to December 10, 2018 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 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the United States Marine Corps from December 1965 to December 1967. These matters come before the Board of Veterans' Appeals on appeal from an April 2018 rating decision that denied an increased rating in excess of 50 percent for PTSD, and the Veteran's claim for TDIU. The Veteran filed his claim for an increased rating for PTSD in October 2016 and a TDIU claim in January 2018. In the April 2018 rating decision, the agency of original jurisdiction (AOJ) denied a rating in excess of 50 percent for PTSD and TDIU. The Veteran was subsequently granted a 70 percent disability rating for PTSD in a December 2018 rating decision, which also continued to deny the Veteran's TDIU claim. Later that month, the Veteran submitted a notice of disagreement, which expressed disagreement with the TDIU denial only as to the December 2018 decision, and did not express disagreement with the award of the 70 percent disability rating for PTSD. The Veteran stated, "Thank you for recognizing the severity of my PTSD by assigning a rating of 70%. I believe that an error or more was made in determining that I do not qualify for individual unemployability[,] and I wish to dispute your decision and explain why to the best of my ability." However, in a VA Form 9, Appeal to the Board, submitted in January 2019, the Veteran stated that he believes the effective date for his 70 percent disability rating for PTSD should date back to January 2018, when he filed his TDIU claim. He specifically checked a box indicating that he was only appealing the issue of the effective date of his 70 percent disability rating for PTSD and entitlement to a TDIU rating. As such, the issue of entitlement to an increased rating in excess of 70 percent from December 10, 2018 is not before the Board. 1. Entitlement to an increased rating for PTSD prior to December 10, 2018 VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran's service-connected PTSD has been evaluated under 38 C.F.R. § 4.130 using the General Rating Formula for Mental Disorders, which assigns ratings based on particular symptoms and the resulting functional impairments. See 38 C.F.R. § 4.130, DC 9411. Under DC 9411, 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; or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms associated with each rating in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list; rather, they serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the DCs. See id. VA must consider all symptoms of a veteran's disorder that affect his or her occupational and social impairment. See id. at 443. If the evidence demonstrates that a veteran has symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the DC, the appropriate, equivalent rating will be assigned. Id. In this regard, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and a veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126. Although VA considers the level of social impairment, it does not assign an evaluation based solely on social impairment. Id. VA must consider all of the Veteran's symptoms and resulting functional impairment as shown by the evidence in assigning the appropriate rating and will not rely solely on the examiner's assessment of the level of disability at the moment of examination. See id. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against an increased rating for the Veteran's PTSD prior to December 10, 2018. The reasons follow. The Veteran's wife submitted a statement in July 2014, wherein she wrote that the Veteran has exhibited increased anger and aggressive behavior. She stated that when in public, he has to have his back to the wall. She stated that they have had to leave concerts due to the Veteran's symptoms and that he gets angry with people for no reason. The Veteran's wife stated that the Veteran has no real friends other than his sisters. She also described the Veteran's difficulties sleeping. During VA treatment in June 2015, the Veteran reported that his most prominent symptoms are arousal and avoidance related, including cognitive and behavioral avoidance, anger, sleep disruption, hypervigilance, startle response, and difficulty concentrating. He also expressed concern about alcohol use, as it is the only way for him to fall asleep. It was noted that the Veteran's symptoms significantly impact his occupational functioning, as he reported that he is unable to work for someone else and his symptoms cause him relationship problems. The Veteran submitted a private assessment by Kevin Laughlin, Ed.D., NCC (national certified counselor), in September 2015. During this assessment, the Veteran reported sleep disturbances, occasional thoughts of self-harm or harming others, memory issues, compulsive behaviors, excessive drinking, and that his wife is now afraid of him due to anger issues. Mr. Laughlin noted that the Veteran acts as a tour guide for European trips to raise money and stated that the Veteran "tells of self-employment in luxury-life experiences of yachts and European vacations, but at same time he struggles with financial hardship." Mr. Laughlin stated that the Veteran's daily routine reflects isolation and loneliness and that he experiences memory loss and cognitive- processing problems. The Veteran was assessed with PTSD. Mr. Laughlin later submitted another statement in July 2016, which reiterated much of the same history and symptoms as his 2015 statement. Mr. Laughlin stated that the Veteran suffers from alcoholism, is chronically depressed and shows clear symptoms of an anxiety disorder and obsessive-compulsive disorder. He stated that, although the Veteran is active in his present life, he is alone and isolated, and lacks the social skills necessary to effectively interact with family and friends. He added that the Veteran is unable to establish intimate relationships with anyone. While the assessments of Dr. Laughlin do not expressly state that the Veteran's condition warrants a higher rating, the Board notes that his findings are inconsistent with the preponderance of the record. As discussed further herein, the Veteran has reported that he has friends, stays in touch with his family, plays tennis with others, helps a friend on his boat every winter, takes group of veterans on guided tours of Europe, and continues to enjoy intimacy with his wife. He has routinely demonstrated cooperative, appropriate behavior, and has expressed that he enjoys group counseling sessions with other veterans. Such findings heavily contradict statements that the Veteran is alone, isolated, unable to establish intimacy, and lacks the social skills necessary to effectively interact with family and friends. Additionally, the weight of the evidence does not support that the Veteran suffers from cognitive process problems, as he has routinely been found to have intact cognition, attention and concentration, with a linear, and goal-directed thought process. He has remained independent in activities of daily living and demonstrated the ability to travel independently overseas. For these reasons, the assessments of Mr. Laughlin are of reduced probative value. During VA treatment in April 2016, the Veteran reported that he had just returned from the Florida Keys and his mood is always better after his trips. He reported frustration that he cannot work more due to irritability and difficulty working with people. He denied a depressed mood or anxiety but indicated that difficulties with focus have impacted his tennis game. He reported hypervigilance and stated that he feels better when he is alone, but also stated that he is looking forward to leading his next tour group through Ireland. He reported that his energy varies and that he gets five to seven hours of sleep per night. On mental status examination, the Veteran was described as cooperative, alert and fully oriented with a linear, goal-directed thought process, no perceptual abnormalities, grossly intact attention and concentration, fair insight and judgment, and no suicidal ideation. Similar findings on mental status examination were noted in treatment records from June 2016, August 2016, November 2016, December 2016, January 2017, May 2018, July 2018, August 2018, October 2018, and September 2020. Although the Veteran's mood has fluctuated and mild memory problems have been noted occasionally, the Veteran has consistently been found to be fully alert, oriented, and cooperative with appropriate behavior, fair insight and judgment, a linear and logical thought process, intact cognition, grossly intact attention and concentration, and no evidence of thought disorder, while denying suicidal ideation on mental status examination. The Veteran participated in individual and group therapy in 2016 for his issues with PTSD and alcohol use disorder. In August 2016, the Veteran reported that he found therapy helpful and that he had improved mood with medication. He reported concentration deficits and stated that he gets five to seven hours of sleep per night. He endorsed hypervigilance in public but stated that he is not disturbed by it and does not want to change it. He reported that he has plenty of energy and continues to enjoy playing tennis and enjoys intimacy with his wife. In October 2016, the Veteran returned from a September 2016 trip to France. He stated that he continues to enjoy trips out of the country. He reported low energy and concentration issues, but findings on mental status examination were relatively unremarkable with grossly intact attention and concentration. The Veteran underwent a VA examination in December 2016. The Veteran reported that he isolates socially and drinks to excess. He stated that PTSD symptoms have impacted his relationship with his wife and family. The Veteran reported that for the past five years, he'd been drinking daily, and that he was unable to go more than a few days in any month without drinking. He stated that over the past five years, he had not worked and mostly tried to stay to himself and avoid dealing with others outside of his small circle of family and friends. Despite this, he reported that his wife is very supportive and that he has regular contact with his children and grandchildren, and consistent contact with his sisters and a few close friends. He was noted to be fully independent in his activities of daily living. He reported that he spends his time exercising and traveling and that he spends a few months per year in Florida, where he helps a friend on his boat. The December 2016 examiner noted the Veteran experienced depression, anxiety, suspiciousness, sleep impairment, disturbances of motivation and mood, difficulty establishing and maintaining relationships, and difficulty in adapting to stressful circumstances. The Veteran was fully oriented with a goal-directed thought process, no evidence of thought disorder, and no suicidal ideation. The examiner indicated the Veteran's overall level of impairment was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. This assessment is commensurate with a 30 percent disability rating. The Veteran underwent another private assessment in June 2017, completed by Jeffrey Beck, LMFT (licensed marriage and family therapist). The Veteran reported symptoms of anxiety, depression, flashbacks, avoidance behaviors, social difficulties, concentration deficits, irritability, anger, insomnia, hypervigilance, and elevated startle response. Although the Veteran was noted to be depressed, restless, and to have moderate impairment in remote memory, the Veteran was fully oriented with a linear thought process, intact recent memory, average intelligence, no perceptual abnormalities, and no suicidal ideation. The Veteran reported that he sponsors overseas trips to Europe and serves as the tour guide, further stating that this allows him to "recon" trips weeks in advance where he will travel overseas by himself to develop the tour. Mr. Beck stated that the Veteran's PTSD causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. While this opinion is probative to the extent that it indicates the Veteran to have some functional impairments caused by his PTSD, it does not specify or opine that the Veteran's overall level of impairment would support an increased disability rating in excess of 50 percent during the relevant period. In October 2017, the Veteran returned to VA mental health after having been absent for more than a year. He stated that he had been tracking the days in a month that he does not drink since 2011, and that he averages between five to seven days per month without drinking. He reported continued hypervigilance, anxiety, and guilt. He stated that he continues to attend weekly group therapy and does not experience withdrawal when he does not drink. The Veteran reported that he enjoys running and playing tennis almost every day. He stated that drinking does not get in the way of these activities. In January 2018, he reported that he occasionally serves as a mate on a chartered fishing boat this his friend operates, where he earns good tips, and that he would be traveling to Florida to do that soon. In April 2018, a VA psychologist was asked to comment on the effect of the Veteran's service-connected disabilities on the Veteran's ability to function in an occupational environment and to identify any functional limitations. The psychologist checked a box indicating that the Veteran has significant difficulty accepting supervision and details of work assignments. No other limitations were noted, and no clinical findings were made. No rationale for this assessment was provided with the psychologist stating only, "Noted impairment gleaned from review of LHI C-file." The psychologist did not cite to any evidence of record, or even cite to the Veteran's lay statements regarding his symptoms. The Board notes that medical opinions without a rationale are not probative. In May 2018, the Veteran reported he was having a "tougher time lately." He reported poor sleep with increased nightmares. He reflected on staying in the Florida Keys over the winter, but stated that he enjoys coming back home to see his family and friends. He stated that the only friends he has are other veterans and that he can find it difficult to get along with others. Although the Veteran again reported that decreased concentration had negatively impacted his tennis game, mental status examinations through the summer of 2018 demonstrated generally stable functioning. The Veteran expressed interest in using gabapentin to treat alcohol cravings. In October 2018, the Veteran reported that he had been in France for the entire month of September. He reported that he takes a group of veterans to Normandy every year. He stated that the trip was good, it gives him a chance to do something productive, and is good for his head. When asked if he had tried gabapentin, the Veteran stated that he was no longer interested. He stated that he is in a good place and handling things well. A mental status examination was unremarkable. The Veteran reported he continued to exercise and play tennis regularly. In December 2018, the Veteran submitted a private psychological assessment from Robert Haynes, Ph.D. Dr. Haynes indicated the Veteran to experience severe depression, almost debilitating anxiety, hypervigilance, insomnia, social isolation, interpersonal difficulty, angry outbursts, and difficulty dealing with the public. Dr. Haynes opined that the Veteran's PTSD is characterized by total occupational and social impairment. He stated that it is within a reasonable degree of medical certainty that the Veteran is unable to obtain or maintain gainful employment and that social and occupational impairments are impeding his ability to work with the public or interact in any capacity in the working world. Among the symptoms that Dr. Haynes applied to the Veteran's PTSD diagnosis were gross impairment in thought processes or communication, inability to establish and maintain effective relationships, grossly inappropriate behavior, intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, and near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. Although occurring after the relevant period for the Veteran's PTSD claim herein, Dr. Haynes provided a similar assessment in February 2021. He stated that the Veteran condition is characterized by total occupational and social impairment and predominantly listed the same symptoms associated with his December 2018 assessment. Dr. Haynes wrote that the Veteran suffers from severe survivor's guilt from Vietnam and that his shame has led to a solitary work history and social impairments throughout his life. He stated that the Veteran last worked full time in 1995 and that his social life is non-existent. The Board notes that Dr. Haynes did not provide a contemporaneous assessment of the Veteran's cognitive functioning and he seemingly overlooked significant evidence reflecting the Veteran's functional abilities that heavily contradict Dr. Haynes's opinion. Notably, the Veteran has taken regular trips to Europe, serving as a tour guide for groups of veterans, while also traveling overseas by himself for the purpose of planning future tours. The Veteran has remained independent in his activities of daily living and has routinely been described as well-groomed with appropriate hygiene. These findings do not support Dr. Haynes's contention that the Veteran experiences intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, or near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. Furthermore, while Dr. Haynes indicated the Veteran to experience gross impairment in thought process or communication, treatment records regularly reflected the Veteran to have a logical, goal-oriented and linear thought process with intact cognitive functioning, while demonstrating the ability to communicate effectively and appropriately. Dr. Haynes stated that the Veteran has difficulty dealing with the public and stated that his social life is non-existent; however, the Veteran has been able to serve as a guide leading tour groups through foreign countries, which would inherently involve the ability to function effectively when interacting with the public. The Veteran has also reported keeping in touch with family and friends alike, and he regularly plays tennis. Additionally, the 2018 and 2021 assessments are internally inconsistent. In 2018, Dr. Haynes reported the Veteran to have a relevant behavioral history of anger and angry outburst with a history of many physical altercations. He also stated that the Veteran had a relevant substance abuse history of alcohol abuse. In 2021, Dr. Haynes stated that the Veteran has no relevant behavioral or substance abuse history. For these reasons, the assessments of Dr. Haynes are of lessened probative value. Furthermore, the Board notes inconsistencies in the Veteran's reports of his functioning and work history that serve to undermine his credibility. For example, at the 2016 VA examination, the Veteran reported that he had not worked in the previous five years. He also reported that social limitations caused him to stay to himself and avoid dealing with others outside of his small circle of family and friends. However, the Veteran's 2015 private assessment stated that the Veteran acts as a tour guide for European trips to raise money and that he "tells of self-employment in luxury-life experiences of yachts and European vacations." The record reflects that the Veteran continued to organize and guide these trips throughout the relevant period. Records reflect that the Veteran would socialize with other veterans on these trips and that he enjoyed them. The Veteran has also separately reported that he sold his photography at art shows until approximately 2014. Additionally, the Veteran has reported visiting a friend in Florida each year and working for tips on his charter boat during the relevant period. Contrary to the Veteran's reports, he appears to repeatedly seek out opportunities to travel and put himself in public or social settings. Whether this work was marginal or not, these findings reflect significant inconsistencies with the Veteran's reported work history and social limitations that lower the probative value of his lay statements. The preponderance of the evidence is against an award of increased rating in excess of 50 percent for the Veteran's PTSD. The listed criteria for a 70 percent rating are largely absent from the longitudinal record, which includes 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; and inability to establish and maintain effective relationships. The Veteran has routinely been found to be fully alert and oriented, and to have intact cognitive functioning with normal speech patterns, fair insight and judgment, appropriate behavior, and a linear, goal-directed thought process. Such findings do not support that the Veteran experiences spatial disorientation or atypical speech. The Veteran's memory impairment is contemplated by his 50 percent disability rating during the relevant time period. The Veteran has maintained independence in activities of daily living, exercises regularly, predominantly presents as well-groomed, and travels often to Florida and Europe, both independently and in groups. This weighs against the Veteran experiencing interference with routine activities, near-continuous panic or depression affecting the ability function independently, neglect of personal hygiene, or difficulty adapting to stressful circumstances. Although the Veteran has reported hypervigilance in public, he stated that he is not disturbed by it and does not wish to change it. Additionally, although the Veteran has reported unprovoked irritability with periods of violence, the record demonstrates only a remote history of physical violence, and the Veteran has repeatedly demonstrated appropriate behavior and the ability to function in public. The Veteran's wife reported that he has never been violent with her, despite episodes of verbal abuse. While the Veteran has anger and irritability issues, the Veteran has utilized coping mechanisms and reported that he has benefitted from individual and group therapy, as well as having a positive response to medication. The Veteran has maintained a supportive, intimate relationship with his wife of over 50 years, has maintained relationships with family and friends, and has repeatedly been described as cooperative. These findings weigh against findings of impaired impulse control or an inability to establish and maintain effective relationships. Thus, the record reflects that the Veteran's psychiatric condition is appropriately compensated by his current 50 percent disability rating, which considers such symptoms as flattened affect, impairment of short and long term memory, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Board acknowledges the clinical findings documented in the Veteran's treatment records and VA examination reports that document that the Veteran expressed a history of thoughts of self-harm, including during a 2015 private assessment, and an incident he described at a December 2018 VA examination that occurred approximately a year earlier. However, the facts of this case are distinguishable from those described in Bankhead v. Shulkin, 29 Vet. App. 10 (2017), in which the United States Court of Appeals for Veterans Claims (Court) held that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas (a 70 percent disability rating under 38 C.F.R. § 4.130). Under the facts of Bankhead, the claimant was noted to have had recurrent suicidal thoughts and behaviors of varying severity, frequency, and duration throughout the relevant appeal period. Here, the Veteran's reports of passive thoughts of self-harm do not cause the level of occupational and social impairment contemplated by the 70 percent disability rating, as the evidence also suggests that the Veteran has not reported a plan or intent to carry out his suicidal ideation and has repeatedly denied experiencing hopelessness. When acknowledging his thoughts of self-harm during the relevant period in December 2018, the Veteran stated that he "never planned to do it." He has routinely denied any suicidal ideation, including in August 2016, November 2016, December 2016, May 2018, July 2018, August 2018, and October 2018. The Veteran has received only conservative treatment and has not required urgent or inpatient care for any psychiatric symptoms. He has remained independent in activities of daily living and maintained intact cognitive functioning and an active lifestyle. As such, the Veteran's overall disability picture does not rise to the level of deficiencies in most areas during the appeal period. For all the reasons stated herein, the preponderance of the evidence is against an evaluation in excess of 50 percent prior to December 10, 2018 for the service-connected PTSD. 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. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 2. Entitlement to 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). The Veteran is service-connected for PTSD and major depressive disorder with alcohol use disorder with a 50 percent disability rating from July 29, 2011, and a 70 percent disability rating from December 10, 2018; scars of the right lower leg and left buttock status post debridement and grafting right leg wound with a 20 percent disability rating from June 15, 2012; bilateral hearing loss with a 0 percent disability rating from July 2, 2011, and a 20 percent disability rating from June 22, 2016; and tinnitus with a 10 percent disability rating from June 15, 2012. Based upon the above, the Veteran's combined rating was 70 percent from June 22, 2016, and 80 percent from December 10, 2018. As such, the Veteran's service-connected disabilities meet the schedular criteria for a TDIU rating. "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 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 above analysis of the Veteran's increased rating claim for PTSD is associated herein. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against a finding that the Veteran is unable to secure or follow substantially gainful employment due to his combined service-connected disabilities. The reasons follow. The Veteran underwent a VA examination in December 2018 coinciding with the effective date of his 70 percent disability rating. The Veteran presented for evaluation unaccompanied, appearing clean, adequately groomed and casually dressed. He was alert and fully oriented. He was described as cooperative with appropriate behavior, although he appeared irritable. His thought process was logical and goal-directed and his thought content showed no evidence of hallucinations, delusions, or mania. His judgment appeared intact. He denied any homicidal ideation in the past or present. He noted that he has had thoughts of hurting himself in the past, about one year or nine months prior, but stated that he never planned to do it. The Veteran reported anxious and depressive symptoms with sleep difficulties, reduced pleasure, and poor concentration. He reported an incident of road rage the previous year in which he confronted another driver, but ultimately, he called the VA crisis hotline to talk it through because he recognized there was no good outcome. The examiner indicated the Veteran's psychiatric disability to be characterized by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. This assessment is commensurate with a 70 percent disability rating. Thereafter, the record indicates only conservative treatment for the Veteran's PTSD. In a January 2019 letter, the Veteran stated that he is unable to focus for more than a minute at a time due to symptoms listed in the December 2018 VA examination report, including unprovoked irritability with periods of violence, suspiciousness, depressed mood, disturbances of motivation and mood, mild memory loss, impaired impulse control, chronic sleep impairment, difficulty adapting to work and stressful circumstances, neglect of personal appearance and hygiene, flattened affect, anxiety, and difficulty establishing and maintaining effective work and social relationships. However, treatment notes in 2020 continued to indicate the Veteran to be alert, oriented, pleasant, and cooperative, in no acute distress, with an appropriate affect. The Veteran remained fully independent in all activities of daily living and was noted to continue to play tennis and perform other activities without significant limitation. As to the Veteran's physical disabilities, in October 2016, the Veteran reported that he used his hearing aids only intermittently. The Veteran underwent a VA examination for assessment of his hearing loss and tinnitus in December 2016. The Veteran reported that the functional impact of his tinnitus is that it interferes with his concentration. He stated that his hearing loss causes him to ask people to repeat themselves, but that his hearing aids help somewhat. The preponderance of the evidence is against a finding that the Veteran experiences communication or cognitive deficits as a result of his hearing loss or tinnitus. The Veteran has routinely demonstrated the ability to interact effectively and appropriately with others throughout the relevant period, without significant difficulties noted. Additionally, recurrent mental status examinations show the Veteran to be fully alert and oriented with grossly intact attention, concentration, and cognition. The Veteran underwent another VA audiological examination in March 2018. The examiner stated that the Veteran's hearing loss would affect his ability to function in a position requiring critical listening in difficult listening environments, and that there would be no functional limitations to working in a career that does not require ongoing communication. It was added that hearing aids and assistive devices would assist in warnings and alerting problems. The record does not reflect that the Veteran has required recurrent and ongoing treatment for his service-connected scars. The scars are located on the right lower leg and left buttock. The Veteran underwent a VA examination for assessment of his scar in December 2016. The examiner indicated that the scars do not impact the Veteran's ability to work. As noted, the Veteran has maintained an active lifestyle with routine travel, exercise, and tennis. The preponderance of the evidence is against a finding that the Veteran is unable to obtain or sustain substantially gainful employment. The Veteran has required only conservative treatment for the service-connected PTSD without the need for inpatient care and has maintained independence in activities of daily living. He has maintained independence in activities of daily living and keeps an active lifestyle. He regularly exercises, travels, plays tennis, and stays in touch with friends and family. He enjoys trips to Florida, hosts guided tours to Europe, and helps a friend on a chartered fishing boat. Treatment records predominantly show that the Veteran is cooperative, alert and fully oriented with a linear, goal-directed thought process, no perceptual abnormalities, grossly intact attention and concentration, fair insight and judgment, and no suicidal ideation. Accordingly, the weight of the evidence demonstrates that the Veteran is capable of substantially gainful employment. Regarding the Veteran's education, training, skills, and work history, the record reflects that the Veteran is a high school graduate and that he attended one semester at the University of Pennsylvania in the 1960s. The Veteran has reported that he is conversational in French and Italian languages. The record reflects that the Veteran worked for Owens Illinois as a machine operator from 1967 to 1995a period of 28 yearswhen he was laid off because his job was outsourced. He has stated that he has had only marginal employment since that time. Thereafter, the Veteran was self-employed as a photographer until approximately 2010, but he reported selling his photographs at art shows until approximately 2014. The Veteran also reported that he worked two summers as a boat salesman in 2006 and 2007 until he was fired after an argument with a customer. The Veteran's December 2016 VA psychological examination report indicated the Veteran's work in boat sales to be full-time work. In 2018, the Veteran reported that he occasionally serves as a mate on a chartered fishing boat that his friend operates in Florida, where he earns good tips. The Veteran has also organized and led tour groups to Europe and has reported taking international trips alone in order to plan the tours. In reference to these trips, the Veteran's 2015 private examiner stated that the Veteran "tells of self-employment in luxury-life experiences of yachts and European vacations, but at same time he struggles with financial hardship." The Veteran's employment history and his international travel experience reflects a diverse skillset and that the Veteran has the capacity for learning, training, and adaptation. These skills do not appear to have been hindered by the Veteran's service-connected PTSD and/or other service-connected disabilities, as he has remained independent and active. These attributes would facilitate the Veteran's return to substantially gainful employment that the Veteran is capable of performing. As to the Veteran's physical capabilities, the record does not reflect significant limitations from the Veteran's service-connected disabilities. The Veteran's scars do not limit his vocational abilities. The Veteran has some hearing difficulties, but these are improved by hearing aids, and he has consistently demonstrated the ability to communicate effectively. While the effects of alcohol abuse could potentially limit the Veteran's ability to perform certain physical tasks, he has maintained a rigorous exercise regimen, including regular running, riding an exercise bike, and playing tennis. He has maintained independence in activities of daily living and is able to travel independently. He has not required urgent or inpatient care for his physical disabilities. The record supports that the Veteran's physical limitations can be reasonably accommodated by restricting the Veteran from work that requires critical listening skills in a difficult hearing environment. Accordingly, the evidence supports a finding that the Veteran is physically capable of performing substantially gainful employment. As to the Veteran's mental capabilities, the record shows him to be capable of performing substantially gainful employment. Despite recurrent symptoms of depression, irritability, anxiety, flashbacks, reported social isolation, memory and concentration deficits, low motivation and energy, hypervigilance, and sleep difficulties, the Veteran has routinely recorded normal findings on mental status examinations, including findings that the Veteran is generally cooperative, alert, and fully oriented, with a linear, goal-directed thought process, no perceptual abnormalities, grossly intact attention and concentration, fair insight and judgment, and no suicidal ideation. Despite reported difficulty getting along with others, the Veteran has maintained relationships with family and friends, reported a supportive and intimate relationship with his wife, leads tour groups to Europe, and serves as a mate on a chartered fishing boat for tips. He has exhibited appropriate behavior and social skills and reported that he enjoys group counseling sessions. Accordingly, the Veteran's PTSD can be accommodated by restricting the Veteran from work that requires frequent social interaction with the general public. Additionally, the Veteran is limited to occupations comprised predominantly of repetitive tasks that can be performed independently without the need for constant supervision. Such limitations would limit the Veteran's potential stressors and alleviate concerns about his social functioning. As such, the weight of the evidence shows that the Veteran is mentally capable of performing 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 work that would result in income at the level of substantially gainful employment. For example, the Veteran's service-connected disabilities would not preclude the Veteran from returning to his past work as a machine operator. The Veteran reported that he excelled in this job because he was able to perform it independently. The reason he stopped performing that job was because the company had outsourced his position. The record supports that the Veteran could perform similar positions that use the same skillset. Additionally, the Veteran is capable of occupations such as a warehouse worker, assembly line worker, or custodian, which are positions that would involve repetitive tasks without significant social interaction, such as a packer and sorter at a warehouse or a custodian at an office building. These are jobs that use everyday skills of lifting, cleaning, and organizing, would be simple and repetitive in nature and could be performed largely independently without the need for constant supervision. Further, such positions would not require constant communication with others or critical listening skills. These examples are not exhaustive but are merely illustrative of potential occupations that the Veteran could perform. This is evidence against a finding that the Veteran is unable to secure or follow all forms of substantially gainful employment due to his service-connected disability or disabilities. For all the reasons described above, the Board finds that the preponderance of the evidence is against a finding that the Veteran is precluded from all forms of substantially gainful employment and, therefore, is not entitled to a TDIU rating. 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 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.