Citation Nr: 21070756 Decision Date: 11/26/21 Archive Date: 11/25/21 DOCKET NO. 14-09 188A DATE: November 26, 2021 ORDER Entitlement to an initial compensable rating prior to August 13, 2021, and in excess of 70 percent thereafter for adjustment disorder with depressed mood is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. FINDINGS OF FACT 1. For the appeal period prior to August 13, 2021, the Veteran's adjustment disorder with depressed mood was formally diagnosed but symptoms were not severe enough either to interfere with occupational and social functioning and did not require continuous medication. 2. For the appeal period beginning on August 13, 2021, the Veteran's adjustment disorder with depressed mood was manifested occupational and social impairment with deficiencies in most areas and without total occupational and social impairment. 3. Throughout the period on appeal, the Veteran's service-connected disabilities did not render him unable to secure or follow a substantially gainful occupation and there is no reasonable possibility that the Veteran is unemployable by reason of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for initial compensable rating prior to August 13, 2021, and in excess of 70 percent thereafter for adjustment disorder with depressed mood have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.125, 4.126, 4.130, Diagnostic Code 9434. 2. The criteria for entitlement to a TDIU 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 on active duty in the United States Navy from September 1966 to September 1969 and in the United States Army from April 1982 to January 1991. These matters are on appeal to the Board of Veterans' Appeals (Board) from a May 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2018, the Board issued a decision which, in pertinent part, denied entitlement to a compensable initial rating for depressive disorder. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2019 Order, the Court granted a Joint Motion for Partial Remand, vacating the Board's July 2018 decision with respect to entitlement to a compensable initial rating for depressive disorder and remanded the matter to the Board. In a March 2020 decision, the Board remanded these matters to the RO for further development. More specifically, the Board directed the RO to consider the April 2019 VA examination as it was conducted after the February 2018 supplemental statement of the case. Also, in the February 2021 Board decision, the Board remanded these matters so that the RO could follow-up with the Veteran and his prior employer to submit a completed VA Form 21-4192. The Veteran was instructed to provide another VA Form 21-4192 in a February 2021 notice letter. However, as of this date, the Veteran has yet to submit the form. Therefore, the Board finds that there has been substantial compliance with its previous remands. Stegall v. West, 11 Vet. App. 268 (1998). These matters now return to the Board for further appellate review. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered because of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Separate ratings can be assigned for separate periods based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim. 1. Entitlement to an initial compensable rating prior to August 13, 2021, and in excess of 70 percent thereafter for adjustment disorder with depressed mood is denied. The Veteran contends that his adjustment disorder with depressed mood symptoms are more severe than contemplated by the rating assigned. Specifically, the Veteran contends that his symptoms warrant a compensable rating prior to August 13, 2021 and a 100 percent rating thereafter due to a marked interference with his daily activities and worsening symptoms. See October 2021 Appellate Brief. The Veteran's adjustment disorder with depressed mood was rated under the General Rating Formula for Psychiatric Disabilities (General Rating Formula). 38 C.F.R. § 4.130. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. "A Veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the Veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Formula for Mental Disorders, a noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9435. A 10 percent rating is assigned when symptoms controlled by continuous medication, cause 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. Id. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). Id. A 50 percent rating is assigned when symptoms such as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships, cause occupational and social impairment with reduced reliability and productivity. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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); and 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; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Id. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all 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 the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, 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 Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in November 2020. As such, the DSM-5 applies, and the GAF scores will not be considered. A review of the record reveals that the Veteran sought mental health treatment from VA and private facilities, as well as, treatment for his other health needs. To the extent that the Veteran's treatment records contain information relevant to the severity of his mental health, to include mental health screenings, the Board will summarize this evidence. Turning to the evidence, at a January 2013 VA examination, the Veteran reported symptoms of depressed mood, chronic sleep impairment, flattened affect and disturbances of motivation and mood. The Veteran denied depression, although he had symptoms of depression. The Veteran reported that he was having symptoms of feeling inadequate and wondering if he was depressed. He was looking for help to improve his performance. At that time, he was working 16-hour days and also on weekends and felt he was burnt out. He denied feelings of sadness, low energy and low motivation. He denied being emotionally numb, as well as, denied having a lot of anger. He denied panic attacks and feelings of worthlessness and does not have poor self-esteem. He denied hopelessness and suicidal and homicidal ideation and he denied visual or auditory hallucinations. The Veteran reported some irritability several times per week, and would get into verbal altercations but not physical altercations with others. He stated that he avoids dealing with people, and avoids talking about his military experience. The examiner stated that a mental condition had been formally diagnosed, but his symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. At the time, the Veteran had been married for 41 years to his wife and it has been his only marriage. The Veteran reported having one child and four grandchildren. He reported having no friends with whom he gets together regularly, and proclaimed he grew up as an extreme introvert. Thus, he avoids most social situations. The examiner observed that the Veteran's speech was normal, and his thought process was within normal limits, but tangential at times and had to be refocused. The examiner noted that his appearance was appropriate and his judgment was good and logical. In a May 2014 treatment note, the examiner noted that the Veteran does not have any clear Axis I diagnosis and there does not seem to be a need for him to be evaluated for medications. There was also no recommended treatment based on the assessment that the Veteran does not meet criteria for an Axis I diagnosis. During the October 2017 VA examination, no symptoms were reported, and the examiner provided no diagnosis as he noted that the Veteran's former service-connected mood disordered had been resolved and no longer exist. The Veteran reported moving from Colorado to Florida to be closer to his daughter and grandchildren. He stated that the move was exhausting, but his neighbors helped him unpack the truck. The examiner noted that the Veteran sought treatment in May 2014 while in Colorado due to having anger dysregulation. However, no Axis I or Axis II diagnosis was offered. Thus, there was no need to be evaluated for medication as no diagnosis was offered. The Veteran was not currently in mental health treatment. When the Veteran was asked to describe any current mental health symptoms, he denied any. The examiner observed that the Veteran appeared as a jovial individual in no apparent distress. He was alert and well oriented in all three spheres. His thought processes were logical to the course of conversation, goal-directed and linear. The Veteran's thought content was free of suicidal or homicidal ideations or intent. In an April 2019 VA examination, the Veteran denied any mental health symptoms. The examiner provided no diagnosis. The Veteran recounted being married for 46 years. He described the marriage as "good." The Veteran reported having close bonds with his daughter and four grandchildren. The Veteran stated that he does not have close friends whom he can confide in and added, "I never have ... I've always been a hermit." The Veteran reported being panic because he moved two years prior, and his wife is physically unable to help set up their new home. The Veteran reported having five beers a week and a little bit of wine before going to bed, because it detracts his brain from gridlock, continuous thinking." He stated that he has not used illicit drugs or abused prescription medications. He reported being retired since he was 68 from a call center. The Veteran reported sleeping five to six hours a night and not needing more than that with his Continuous Positive Airway Pressure (CPAP) machine. The Veteran denied current suicidal or homicidal ideations. He denied any attempts to harm himself. There were no signs or symptoms of mania or hypomania. There was no evidence of psychosis. The examiner observed that the Veteran was alert and fully oriented. He recalled 3/3 items immediately and 3/3 items after a delay of a few minutes with two prompts. In a January 2020, correspondence letter, the Veteran reported that he is depressed but he covers it up. He reported depriving himself from sleep and drinking wine to help him sleep. He also mentioned that his sex life had reduced. In an August 2021 VA examination, the examiner diagnosed the Veteran with adjustment disorder with depressed mood, which is related to his service-connected disabilities and noted that he had 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. The examiner noted symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, difficulty in adapting to stressful situations and an inability to establish and maintain effective relationships. The examiner also noted that the Veteran is a 77-year-old married male and has been married for 49 years. He has a good marriage with his wife, and he has friends who are neighbors. The Veteran stated that if he needs help or advise, he does not go to anyone. When asked if he is under mental health treatment, the Veteran stated that he "was in sales and was able to control himself and he studied philosophy." The Veteran reported problems with anger, frustration, irritability, sadness, and difficulty with motivation. He denied suicidal thoughts and reported being under stress due to the situation with his wife. The examiner noted that the Veteran had moderate difficulty describing his depression. The Veteran stated that he became "dull" as a result of a car accident while in service, which resulted in a traumatic brain injury (TBI). He was discharged from the service due to "burning out." The Veteran stated that he has been a "vegetable," since the accident. He stated that he had to sit in a corner and read a book, and could "not work too much." The Veteran reported that he can dress, bathe, groom, cook, clean, and do laundry, as well as, cares for his wife. He is able to run errands and drive. However, he stated that he procrastinates and has to work slowly and becomes easily overwhelmed. The Veteran reported having no trouble with orientation and remembering names. He sometimes forgets where he is driving due to distraction and he has difficulty concentrating. Further review of the record shows that the Veteran receives treatment at the VA Medical Center for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has reported symptoms that are worse than those noted in the VA examination reports of record. Based on the foregoing, the Board finds that a compensable rating prior to August 13, 2021 is not warranted. In this regard, the Board finds that such disability was a mental condition that was formally diagnosed, but symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. In his January 2013 VA evaluation, he reported impaired sleep, depressed mood, and disturbances of motivation, but denied depression, sadness, panic attacks, hallucinations, anxiety, suicidal and homicidal ideations. The Veteran reported staying married to the same woman and having a good relationship with his child and grandchildren. The examiner found that his symptoms were not severe enough to interfere with his occupational and social functional and noted that his depression seemed to be in remission and he did not meet the criteria for a mood disorder. The Veteran reported avoiding social settings, but also proclaimed that he grew up being an introvert. In the May 2013 treatment note, it was noted that the Veteran symptoms did not rise to the level of a diagnosis and medication could not be provided, because of the lack of a diagnosis. In the October 2017 VA evaluation, the Veteran reported no symptoms at all, and a diagnosis was also not provided. In his April 2019 evaluation, the Veteran stated that he had no symptoms and that he avoided social interactions, because he had always been a hermit. The Veteran reported that his marriage was good and that he moved closer to his daughter and grandchildren. He reported being panicked about having to organize the house due to the move and having to take care of his wife. He reported sleeping five to six hours a night, although he usually took wine to help him sleep. He denied suicidal and homicidal ideations and had normal judgment and speech. In his January 2020 correspondence the Veteran self-reported having depression but stated that he covered it up. Prior to August 13, 2021, the Veteran had multiple evaluations where no diagnosis could be established. He actively denied depression in multiple evaluations, although he stated that he had depression in his correspondence. In the January 2013 examination, the Veteran reported that he worked at T-Mobile for nine years until the call center was outsourced to another company, not because of his symptoms. Such does not constitute 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. For the period after August 13, 2021, the Board finds that a rating in excess of 70 percent for adjustment disorder with depressed mood is not warranted. In this regard, the Board finds that such disability was not manifested by total occupational and social impairment. The record reflects that the Veteran's symptoms have not been consistent with total occupational and social impairment such that a 100 percent rating is warranted at any point during the appeal period. Total social impairment was not demonstrated as the Veteran maintained a relationship with his wife for 49 years that he described as good, along with making friends with his neighbors when he moved to Florida, which was an improvement from previously living as a hermit and not having any friends. The Veteran also maintained a relationship with his daughter and grandchildren. Such does not constitute total social impairment. Moreover, the Veteran has not displayed gross impairment in thought processes or communication nor has the record shown that he is a persistent danger of hurting himself or others or grossly inappropriate behavior. The Veteran did not report homicidal or suicidal attempts, nor were there evidence of hallucinations, delusions, or obsessive rituals. Although the Veteran had memory loss, it was reported as mild. While the Veteran reported that he had difficulty with concentration and sometimes gets distracted when he is driving, he has not displayed disorientation to time or place, or memory loss for names of close relatives, his prior occupations, or his own name. Additionally, there is no evidence or allegation that he was unable to maintain minimal personal hygiene. Psychological examinations during the appeal period consistently found the Veteran's grooming and hygiene to be appropriate, adequate or good. There is no evidence or allegation that the Veteran's psychiatric symptoms manifested in interference or difficulties resulted in the inability to perform activities of daily life, to include maintenance of minimal hygiene. In fact, not only is the Veteran taking care of himself, but he is also taking care of his wife. Moreover, this is not a disability picture indicating total occupational and social impairment at any time during the appeal period. In making its determination in this case, the Board acknowledges the Veteran's belief that his adjustment disorder with depressed mood symptoms are more severe than the current rating reflects. While the Board recognizes that the Veteran is competent to provide statements regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Moreover, while the Veteran reported education as corpsman during service, there is no evidence or suggestion that he underwent further medical training. Rather, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability considering the rating criteria to be more persuasive than the Veteran's reports regarding the severity of his condition. The Board notes the contentions of the Veteran and his representative that the Veteran's adjustment disorder with depressed mood is more severe than currently shown on examination. The Board acknowledges the Veteran's reports of having depressed mood and minimizing its effects as a coping mechanism. However, although the Veteran's August 2021 VA examination closely appropriates the severe symptoms the Veteran emphasizes, they still did not rise to total occupational and social impairment, and a higher rating are not met. The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). This argument is therefore without merit. The Board has considered whether a staged rating under Hart v. Mansfield, supra, are warranted, however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning further staged ratings is not warranted The Veteran and/or his representative has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that an initial compensable rating prior to August 13, 2021 and a rating in excess of 70 percent for adjustment disorder with depressed mood is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Entitlement to a TDIU is denied. The Veteran contends that his service-connected disabilities, especially his TBI, has deemed him unable to obtain and maintain substantially gainful employment. See January 2020 Correspondence. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Rating boards should submit to the Director of Compensation Service for extraschedular consideration all cases of Veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when adjudicating a TDIU claim, VA must take into account the individual Veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran's master's degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). An assessment of TDIU entitlement based on the combined effects of all service-connected disabilities should address all such disabilities. Therefore, the cumulative effects (functional impairment) of all service-connected disabilities should be addressed in determining if the service-connected disabilities prevent substantially gainful employment. Floore, 26 Vet. App. 376; accord Geib v. Shinseki, 733 F.3d 1350, 1353-54 (Fed. Cir. 2013). The ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. 38 C.F.R. § 4.16(a); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). For the appeal period, the Veteran had a combined 90 percent rating for the following service-connected disabilities: adjustment disorder with depressed mood (rated as zero percent disabling from September 28, 2012 and 70 percent disabling from August 13, 2021); lumbosacral degenerative joint disease (rated as 10 percent disabling from September 28, 2012); tinnitus (rated as 10 percent disabling from September 28, 2012); right elbow degenerative joint disease secondary to epicondylitis and tendinitis (rated as 10 percent disabling from July 30, 2021); right forearm impairment (rated as 10 percent disabling from July 30, 2021); residuals left hand injury with fracture of middle finger (previously evaluated under diagnostic code 5299-5226) (rated as 10 percent disabling from July 30, 2021); residuals right ankle fracture at distal fibula with history of inversion injuries (rated as 10 percent disabling from July 30, 2021); traumatic brain injury (rated as 10 percent disabling from July 30, 2021); residual scar, right index finger laceration (rated as noncompensable from May 29, 1992); left anterior thigh lipoma (rated as noncompensable from May 29, 1992); bilateral hearing loss (rated as noncompensable from September 28, 2012); right elbow limitation of extension (rated as noncompensable from July 30, 2021). The combined rating is 20 percent from September 28, 2012, 50 percent from July 30, 2021 and 90 percent from August 13, 2021. Therefore, the criteria for consideration of a TDIU pursuant to 38 C.F.R. § 4.16(a) has been met on August 13, 2021. However, when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for a TDIU set forth in 38 C.F.R.§ 4.16(a), the case may be referred to appropriate VA officials for consideration of assignment of a TDIU rating. 38 C.F.R. § 4.16(b). Turning to the functional impact of the Veteran's disabilities, the January 2013 VA examiner for his psychological disability stated that the Veteran's symptoms are not severe enough either to interfere with occupational functioning. The Veteran stated that he worked for Gubb-Ellis and did projects for a defense contractor. He worked for them for a year and a half and then he was recruited for another job as office manager. His longest job was at T-Mobile for nine years at a call center in collections. He lost that job because they closed the call center and outsourced it. The Veteran reported that he did a good job for his employers and they were happy. He noted that when he was working, he did not go to work late, leave early or miss days of work. During the examination, the Veteran stated that he was looking for work. He also stated that he started his social security benefits at 66, and started military retirement when he was eligible. He noted problems with both concentration and distractibility and had short-term memory problems, where he forgets things. The Veteran also stated that his biggest worry was that his "legs are bad." He said he had leg movement problems, and although his finances are difficult, and he does not think he can retire. In the October 2017 VA examination for TBI, the examiner noted that the Veteran's residual conditions attributable to his TBI did not impact his ability to work. In the January 2020 Correspondence, the Veteran reported that, during service, he was fired for being too dull to accomplish tasks and that he knew what he should be doing but could not do it. He was burned out and damaged with the TBI. The Veteran stated that only part-time employment was obtainable to him and meant he had to work two jobs. He reported that one of his employment, a jeweler remained steady, while his other part-time jobs keep changing until he made the jewelers job permanent. The Veteran also described that while working at the call center, he felt extreme pain in both legs, his knees and below and experienced mental slowness, and that he announced his retirement date to avoid getting fired. However, the call center was closed a month and half before his retirement date. After retirement, the Veteran states that he was able to elevate his legs and limited his mental activity which help eliminate most of his pain. But the Veteran believed that he would not be able to handle full-time employment because of the discomfort and pain. In an August 2021 psychological VA examination, the Veteran reported that he worked in sales and retail and stated that he was always employed. The examiner noted that the Veteran sustained a TBI in 1990 when he was struck by a car. The Veteran stated that he has been a "vegetable" since the accident. He stated that he had to sit in a corner and read a book and could "not work too much" during 1989 to 1990, when he was working 80 hours per week while on active duty. He admitted to terminations due to poor attendance in 1989 and reported that he retired nine years prior from a call center in collections. He indicated that he had memory problems and difficulty concentrating and had trouble adapting to work environments. The Veteran reported that he continued to struggle with depression. He stated that he held a job where he was able to perform the job task but if he "worked one year overtime" he would not be able to handle it. In an August 2021 VA examination for degenerative arthritis, the Veteran reported difficulty with walking, standing and sitting for long periods of time and also difficulty with climbing ladders, bending, lifting, carrying and running. The examiner noted that these lead to issues with the Veteran completing physical tasks at work. In an August 2021 VA examination for TBI the examiner noted that the Veteran's head injury has led to multiple residuals, including memory loss, and aphasia which make it difficult for the Veteran to complete administrative tasks at work. As previously mentioned, in April 2020, the Veteran submitted a VA 21-4192 Request for Employment Information in Connection with Claim for Disability Form for his employer T-Mobile that was not complete. The Veteran was notified to submit a completed version, but the Veteran failed to submit one. In an April 2020 Veterans Application for Increased Compensation Based on Unemployability (VA Form 21-8940), the Veteran reported that he could not stand or sit, repetitively, for more than four or five days a week because of his disabilities. The Veteran reported that he worked at T-Mobile in the call center, 40 hours a week from June 2003 to June 2012 and he lost no time from illness. The Veteran reported that he announced his retirement but the call center closed a month and a half earlier. He also mentioned that he wanted to retire because he could sit through a meeting and not be able to remember anything that was said. He could not stand the pain in his legs. Here, the evidence is against finding that the Veteran is precluded by his service connected disability from obtaining and maintaining any form of gainful employment consistent with his education, experience, and skillset. The record shows that the Veteran's had attained a college degree and was previously employment in a call center. The ultimate question is whether he is capable of performing the physical and mental acts required by employment, not whether he can find employment. 38 C.F.R. § 4.16(a); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Based on the foregoing, the Board finds that the Veteran is not entitled to a TDIU at any time during the period on appeal. The Board has carefully considered the Veteran's statements regarding the effects of the aggregate effects of impairment of his service-connected disabilities, to include an adjustment disorder and a TBI, on his employability. Although the Veteran experienced limitation as a result of his service-connected disabilities, and these disabilities have been found to cause some impact on his daily functioning and earning capacity, that impact was considered in the schedular ratings currently assigned. Simply stated, if he did not have impairment with his service-connected disabilities, there would be no basis for the combined ratings during the period on appeal. Thus, such disabilities are not shown to render the Veteran unable to secure or follow a substantially gainful occupation. The fact that he was having impairments or difficulties does not provide a basis to grant TDIU. Significantly, the Veteran mentioned that he retired because of the pain in his legs and because he had difficulty concentrating and remembering what was said. However, the Veteran reported on his VA Form 21-8940 that he worked full-time and he did not have loss time from his disabilities. The Veteran also reported that he was terminated from his employment in 1989 because of the symptoms he experienced with TBI from his accident, but this was before he was service-connected for any disabilities. Furthermore, the Veteran stated that although he was experiencing symptoms, he still worked 80-hour weeks. Thus, indicating that his disabilities did not preclude him from performing the physical and mental acts of gainful employment. Thus, the Board finds that the preponderance of the evidence tend to show that the Veteran's service-connected disabilities do not prevent the Veteran from obtaining or maintaining gainful employment. As the evidence fails to reflect that service-connected disabilities prevent substantially gainful employment or that there is sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his service-connected disabilities, the Board further finds that referral to the Director, Compensation Service for consideration of entitlement to TDIU on an extraschedular basis is also not warranted. 38 C.F.R. § 4.16(b). Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to TDIU. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Accordingly, the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Adeyemi, 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.