Citation Nr: 21011997 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 12-33 236 DATE: March 3, 2021 ORDER 1. Entitlement to service connection for a psychiatric disorder, to include schizophrenia and schizoaffective disorder, is denied. 2. Entitlement to referral for consideration of a total disability rating for compensation based on individual unemployability (TDIU) on an extraschedular basis is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran’s psychiatric disorder, to include schizophrenia and schizoaffective disorder, had its onset during active service, manifested within one year of service discharge, or is otherwise related to an in-service injury or disease. 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 service connection for a psychiatric disorder, to include schizophrenia and schizoaffective disorder, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.384, 4.125. 2. The criteria for referral for an extraschedular TDIU rating 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 from February 1981 to February 1985. The Veteran’s claim for service connection for depression and anxiety was initially denied in a February 2006 rating decision, and a subsequent claim for service connection for schizophrenia, which was construed as an application to reopen the claim for service connection for depression and anxiety, was denied in August 2007. The claim was reopened in a November 2019 Board of Veterans’ Appeals (Board) decision, and the matters herein were remanded in order to obtain outstanding records and to schedule the Veteran for a VA examination in order to determine the nature and etiology of his psychiatric condition. The required development was completed, and a VA examination took place in January 2020. 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 Veteran has alleged that he began to experience symptoms of a psychiatric disorder, to include schizophrenia, during service, possibly precipitated by an assault and facial injury that he incurred in October 1982. He has reported his symptoms, to include persistent auditory and visual hallucinations with acute paranoia, as well as depression and anxiety, started in service and continued following service discharge. The Veteran’s representative has asserted that the Veteran’s psychiatric disorder was demonstrated by the Veteran’s behavior and disciplinary issues during active duty, and the fact that the Veteran did not receive treatment for a psychiatric disorder for 20 years following service is itself a marker of a severe thought disorder. The Veteran has stated that his failure to receive necessary treatment during service cost him his career. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against an award of service connection for a psychiatric disorder. Additionally, 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. The reasons follow. 1. Entitlement to service connection for a psychiatric disorder In general, under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 U.S.C. § 5103(a). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as a psychosis, such as schizophrenia and schizoaffective disorder, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a), 3.384. Although the evidence supports the existence of a present disability, the preponderance of the evidence is against a causal relationship between the Veteran’s present disability and an in-service incurrence or aggravation, which is explained in detail below. The Veteran’s service treatment records show that, in October 1982, the Veteran was in a fight with a fellow serviceman, received a laceration on the bridge of his nose, and sustained undisplaced fractures of his nose and right mandible. He was hospitalized for approximately six weeks. The Veteran was found not at fault for the October 1982 fight. In May 1983, the Veteran was transferred to California due to adjustment problems. In October 1983, the Veteran tested positive for cocaine. In October 1983, the Veteran received an Article 15 punishment for leaving his appointment place of duty. In a May 1984 Health Questionnaire for Dental Treatment, the Veteran checked no to the question of whether there had been a change in his health in the last two years. In May 1984, the Veteran received a promotion based on a finding that the Secretary of the Army had “reposed special trust and confidence in the patriotism, valor, fidelity, and professional excellence” of the Veteran. In August 1984, the Veteran was accused of being disorderly and attempting to initiate a physical altercation. In February 1985, the Veteran received an honorable discharge from the Army. In September 1985, the Veteran submitted an Application For Correction of Military or Naval Record Under the Provisions of Title 10, U.S. Code, Sec. 1552, where he requested that his re-enlistment code be changed so that he could “be able to further [his] career or duties to the military.” An April 1987 document from the Department of the Army denied the Veteran’s request to have his re-enlistment code changed to allow him to re-enlist. The Veteran also made multiple unsuccessful attempts to change his record to allow for re-enlistment in 1994. The record does not indicate that the Veteran sought psychiatric treatment for many years following his discharge in 1985. However, VA treatment records show that the Veteran voluntarily participated in multiple VA research studies during the early 1990s. In October 1990, VA records show that he was screened for participation in a research study involving blood pressure, but that the Veteran’s blood pressure did not meet the inclusion criteria for further participation. The Veteran also participated in a research study for “mood, memory, and cardiovascular risk factors,” for multiple months in July 1991. That month, the observing psychologist wrote that the Veteran was unemployed and reported he had not slept in 48 hours, but that the Veteran appeared attentive and energetic. He wrote the Veteran reported alcohol consumption and a moderate level of depressed mood and wrote that the Veteran’s current life stressors suggested possible depressed mood. No symptoms were attributed to the Veteran’s service. On follow-up for the research study in September 1991, a psychologist noted that the Veteran seemed more distracted and inattentive today, but that the Veteran gave tasks his best effort. The psychologist wrote that the Veteran did not provide spontaneous conversation and had little eye contact, but he denied any symptoms of depressed mood. The Veteran also participated in a research study entitled, “Effect of Brief Nursing Interventions on Alcohol Consumption and Readiness to Change in Veteran Drinkers.” The purpose of the study was to evaluate different approaches to providing feedback on a person’s drinking patterns and the effect they may have on one’s health. During screening in June 1991, the Veteran described a history of excessive drinking and stated that his nerves were on edge. The Veteran reported that he was unemployed and that his last alcohol/drug use was the prior day. The Veteran reported he first used alcohol when he was 13 years old and first used drugs when he was 15 years old. The Veteran denied any current psychiatric medication, denied ever making a suicide attempt, and denied suicidal or homicidal ideation. When asked if the Veteran currently or recently experienced any symptoms of serious mental illness (hallucinations, paranoid delusions, ideas of reference, loose association, severe depression, hypomania, etc.), the VA clinician wrote “None.” When asked if, based on the interview impression, the Veteran displayed symptoms of significant cognitive deficits, memory impairment, concrete, illogical thinking, or markedly poor judgment disorientation, the VA clinician wrote “None.” A November 2001 VA treatment record shows that the Veteran was seem for complaints of pain following a January 2001 motor vehicle accident. The Veteran was living with his girlfriend and one son and had been unemployed for the last month. A review of systems shows that when the examiner addressed “psych,” he wrote the Veteran denied depression and denied suicidal and homicidal ideation. The examiner described the Veteran as fully alert and oriented. During VA treatment in August 2002, the Veteran denied depression, homicidal ideation, and suicidal ideation. The examiner described the Veteran as alert and oriented. A depression screen and military sexual trauma screen were both negative. A February 2003 VA treatment record shows that the Veteran was seen for pain in the left great toe. The Veteran denied alcohol intake and reported he lived with his family. Physical examination showed that psychiatric findings were normal. In January 2005, a depression screen was again negative. An April 2005 VA treatment record shows that a PTSD screen was negative. In a separate April 2005 VA treatment record, the Veteran sought treatment for right wrist pain. When going over the Veteran’s social history, the examiner noted that the Veteran was in the Army from 1981 to 1985 and currently drinks two beers a day. The Veteran reported he was working for a paper company but was not able to work over the last two to three months because of wrist pain. The following month, he was requesting “disability” because he said he could not use his right hand well. A July 2005 VA treatment record shows that the Veteran reported he was having problems adjusting to not being able to work and that he felt depressed. He reported not sleeping well and getting anxious at times. Psychiatric examination showed only that the Veteran was alert and oriented. In September 2005, when the Veteran first filed a claim for service connection for a psychiatric disorder with VA, he attributed depression to his medical conditions and not to his military service. The Veteran also applied for Social Security Administration (SSA) disability benefits in September 2005 and reported that the illnesses, injuries, or conditions that limited his ability to work were “depression, arthritis, borderline diabetic, and leg nerves.” When asked when he became unable to work because of his illnesses, injuries, or conditions, the Veteran documented February 1, 2005. He also reported this as the date that he stopped working. The Veteran added that he was in too much pain with his legs and right arm and that “the depression makes me want to stay to myself most of the time.” Within the application material submitted in 2005 to SSA, the Veteran did not report symptoms, such as hallucinations or other symptoms indicative of psychosis. https://medlineplus.gov/psychoticdisorders.html He described having difficulty seeing people having a good time and that he would mostly stay inside and noted he used to go outside a lot with his son. He described having difficulty dealing with pain and swelling in his extremities and that he now took medicine for depression and anxiety. A November 2005 SSA psychiatric assessment, covering the period from February 2005 to October 2005, shows that the examiner found the Veteran had an affective disorder and an anxiety-related disorder. Not checked on this form is the part that addresses “Schizophrenic, Paranoid and Other Psychotic Disorders.” In January 2006, in an SSA Functional Report, the Veteran described his daily activities and other activities. He wrote that before his illness, he was an upbeat person, outgoing, and tried to keep a job and tried to handle his pain for as much as he could. He described that it had gotten to be too much and was trying hard to keep his mind intact. At a VA follow-up appointment in March 2007, the Veteran told an examiner that his younger brother had been recently murdered and that he was still trying to get over this. A PTSD screen performed at that time was negative. The examiner wrote that the Veteran’s depression was stable with Prozac and took Trazodone for insomnia. Soon thereafter, the Veteran underwent substance abuse treatment at VA. In April 2007, the Veteran reported a more than 20-year history of substance abuse, including using alcohol, cocaine, marijuana, hashish, hallucinogens (“PCP”), and Valium. He described using alcohol, cocaine, and marijuana daily, but denied other recent drug use. The Veteran reported that he first drank alcohol at age 9, began smoking marijuana at age 13, and began using cocaine, heroin, and hallucinogens in the early 1980s. The Veteran reported he regularly abused drugs after leaving the military and that he lost jobs as a result. In the same month, the Veteran began to report some symptoms, including hallucinations, that had not been documented previously either by medical professionals or reported by the Veteran when describing the Veteran’s psychiatric symptoms. It was the first time the Veteran was documented to be assessed with psychosis. He was assessed with prolonged depressive reaction and polysubstance dependence and was referred for a VA rehabilitative program. In May 2007, the Veteran reported being paranoid and keeping the house locked down, continuing to have audio/visual hallucinations, having nightmares about the military, and not being able to work due to paranoia and symptoms of PTSD. The assessment entered by the nurse practitioner was schizoaffective disorder, polysubstance dependence. In June 2007, the Veteran reported that he continued experiencing auditory and visual hallucinations and continued to feel moderately paranoid. He reported he had his first psychotic break at age 20, when he was in the military. The Veteran reported he saw a substance abuse counselor while in service but there was no psychiatric evaluation and, thus, no psychiatric treatment. The Veteran was diagnosed with chronic paranoid schizophrenia and polysubstance dependence. In a July 2007 statement, the Veteran reported he had been a good soldier until August 10, 1983, which corresponds with the date of the Veteran’s first positive drug screen during service at age 22. He reported he saw a substance abuse counselor one time, but he continued to have problems. He wrote that his commander would not give him help. The Veteran submitted documentation to SSA in 2007 in which he reported symptoms of paranoia hallucinations, symptoms which had not been reported in his 2005 application for SSA disability benefits. In a December 2007 examination performed in connection with his claim for SSA disability benefits, the Veteran reported he began hearing voices in 1985 when the Veteran would have been 23 or 24. He stated he was presented to a psychiatrist at that time and was placed on unknown medications for 6 months. As the Veteran was discharged in February 1985, this would have at least partially occurred after the Veteran’s discharge from active duty, but no treatment records support the notion that the Veteran sought or received any treatment. He said he self-discontinued the medication, continued to have auditory hallucinations, and developed depression. The examiner entered a diagnosis of “Mental health disorder” and suggested further evaluation. The Veteran continued to report symptoms of paranoia and hallucinations, consistent with concurrent assessments of schizophrenia. In an August 2008 Case Analysis performed by a psychologist in connection with the Veteran’s claim for SSA disability benefits, the examiner noted that prior to September 2007, there were no medical records citing a diagnosis of schizophrenia. In September 2010, the Veteran reported that subsequent to his October 1982 fight with a fellow serviceman, he became depressed, anxious, and always had his guard up. He reported hearing voices telling him not to eat food because it is not safe. A July 2011 VA treatment record shows that the Veteran reported he first started experiencing auditory hallucinations at the age of 19 while in the Army, which would have been during his first five months of service in 1981. He related that the voices were of a warning stating things like "you've got to watch everybody, don't trust nobody." He stated that this affected him to the point where, when he got food, he would cut it up into very small pieces to ensure that there was nothing harmful in it. He reported that he began to isolate from others at that time and that he was not able to sleep at night. He described visual hallucinations in his peripheral visual fields, "like shadows that were following me." He described experiencing significant paranoia and reported having several incidents in which he was shooting a gun at shadows because he thought that they were out to hurt him. A July 2014 VA treatment record shows that the Veteran reported he first noticed auditory hallucinations at age 21 while in the military, but he indicated these symptoms were prior to the October 1982 assault incident. He stated that he had become so frightened from the voices that he pulled the covers over his head at night. He stated he tried to stay to himself, but another soldier hit him and broke his nose. He reported that this heightened the paranoia, and he stopped trusting anyone. In August 2019, the Veteran’s representative submitted an opinion and examination report by Dr. Michael Cesta, wherein Dr. Cesta concluded that the Veteran had schizophrenia, which had begun in 1982 and continued to the present time. Dr. Cesta found that the Veteran had no evidence of psychiatric illness, substance use disorder, personality disorder, neurologic disease, brain injury, or any other central nervous system prior to his active duty. He indicated the Veteran was not cognitively intact at the time of examination. When laying out the medical chronology, Dr. Cesta did not address the medical records from the 1990s to 2006, which do not document reports of hallucinations or psychiatric symptoms indicative of a psychosis. https://medlineplus.gov/psychoticdisorders.html He provided a detailed explanation for why he believes that schizophrenia had its onset during the Veteran’s service sometime between 1982 and 1983. The Veteran underwent a VA examination in January 2020 following the November 2019 Board remand. The examiner stated that it was less likely than not that the Veteran’s psychiatric disorder related to the Veteran’s military service from 1981 to 1985. Although confirming the diagnosis of schizophrenia, the examiner stated that the Veteran’s age at diagnosis and the fact that psychotic symptoms were not reported earlier was atypical. The examiner stated that the Veteran did not have a diagnosis or treatment for schizophrenia during active duty and that medical records are silent for psychosis until 2007. The examiner reviewed the personal and lay statements of record, but stated that, for a complex psychiatric condition such as schizophrenia, medical records are more likely able to provide specific symptoms reported by professionals that are due to this diagnosis alone (and not due to other etiology). As to the Veteran’s substance abuse, the examiner stated that the Veteran has a well-documented history of alcohol and drug abuse and that he has reported being sober for years now. She found that there is an established correlation with substance use and schizophrenia, although the specific nature of the relationship is not clear. The examiner stated that the Veteran's documentation of alcohol and drug problems had its onset approximately 25 years prior to the report of psychotic symptoms and the Veteran has maintained sobriety through his current diagnosis of paranoid schizophrenia. The examiner stated that, given a long history of substance use with no schizophrenia diagnosis and no current substance use diagnosis with a current diagnosis of schizophrenia, it is difficult to specify the nature of the relationship between the two. The examiner also indicated that the Veteran’s SSA records in which the Veteran alleged depression and anxiety due to pain and separate medical conditions do not appear to have a bearing on his current schizophrenia diagnosis. In April 2020, the Veteran’s treating VA psychologist submitted a mental disorder disability benefits questionnaire, in which she confirmed the Veteran’s diagnosis of schizophrenia. The examiner stated that the Veteran suffered a psychotic break at age 20 while in the military, but did not provide further information as to when, specifically, the break occurred or upon what facts she based that conclusion. She did not acknowledge any clinical findings from the Veteran’s treatment records or address any treatment prior to 2007, when she stated that the Veteran completed a substance abuse treatment program and had been sober since that time. She noted that schizophrenia is caused by genetics but is exacerbated “or brought forth by extreme stress such as the military.” Dr. Cesta submitted an addendum opinion in November 2020, in which he again interviewed the Veteran, clarified his August 2019 assessment, and detailed the Veteran’s longitudinal treatment history missing in his prior report. The Veteran was assessed with schizophrenia but did not meet the diagnostic criteria for any anxiety, mood, or personality disorder. He stated that substance use disorder was a component of the Veteran’s schizophrenia, which developed while the Veteran was on active duty. Dr. Cesta indicated that beginning in 2007, the Veteran consistently endorsed persistent psychotic symptomology since 1983 and that the Veteran waited about 20 years to obtain treatment due to fear, suspicion, and paranoia. Dr. Cesta stated that the Veteran’s first symptoms of mental illness “unquestionably” began while on active duty between 1982 and 1983. He stated that features of schizophrenia prevented the Veteran from seeking treatment and that his diagnosis was not immediately evident upon seeking treatment because the Veteran was “unable to describe, in understandable terms, the full breadth of his symptomology. The Veteran never understood the onslaught of his symptoms he was experiencing, and this lack of understanding was further complicated by persistent drug use over the course of decades.” He stated that the Veteran’s history of substance use disorder is not a separate diagnosis of schizophrenia but instead is a concomitant disorder experienced in tandem with schizophrenia and that the Veteran’s schizophrenia was not properly addressed until he received treatment for substance abuse in 2007. Dr. Cesta stated that although the Veteran made intermittent attempts at working after service, the Veteran “could not handle even the most basic tasks or interpersonal interaction, as he was paranoid, bizarre, threatening, and created a frightening and unsafe workplace for his fellow employees. The deterioration in the [V]eteran’s capacity to engage in intellectual thought, pursue task completion, follow directions, communicate effectively, and engage appropriately with other individuals was destroyed entirely by schizophrenia.” Dr. Cesta added that, “[s]ocially, the Veteran only interacts with his immediate family, which has been the case since his discharge from active duty service. The veteran has no friends or acquaintances with whom he engages, does nothing for pleasure, has no hobbies, and struggled with all aspects of day-to-day life.” Dr. Cesta stated that he performed a Miller-Forensic Assessment of Symptoms Test (M-FAST) which did not indicate malingering and suggested a small likelihood of fabrication of symptomology. Dr. Cesta stated that, combined with his clinical interview, there was no evidence that the Veteran lacked veracity or was a poor historian regarding the description of his impairments over time. Dr. Cesta concluded by saying that the Veteran is likely to require long-term institutionalization or a long-term care facility for his chronic and pervasive mental illness within the next several years, and stated that he is wholly and thoroughly disabled from psychiatric disease and has been since his discharge from active duty. As a preliminary matter, due to a lack of diagnoses and findings relating to the Veteran’s condition from his time in service and thereafter, some of the opinions rendered relating to the Veteran’s current condition since 2007 are based on the Veteran’s own reports and allegations of events that occurred approximately 20 to 35 years prior. Although the Veteran is competent to report his observed symptoms, a review of the record shows significant discrepancies in statements regarding his condition over time, which serve to undermine his credibility and reduce the probative value of opinions that rely on the Veteran’s self-reporting. For example, in July 2011, the Veteran stated that he first experienced auditory hallucinations at the age of 19 while in the Army, which would have been in 1981. During VA treatment in March 2020, he stated that he first experienced auditory hallucinations around age 20 and that he went to “sick call” multiple times to report his hallucinations, but he never received treatment and was never allowed to see a doctor. In July 2014, the Veteran stated that his hallucinations began at age 21, but prior to the October 1982 assault that injured his jaw and nose. However, separately during VA treatment in September 2010, the Veteran reported that he began to hear voices following the October 1982 fight. This claim has been repeated, including in the September 2017 brief of the Veteran’s representative, contending that the Veteran’s symptoms were onset at the time of this fight. In a July 2007 statement, the Veteran reported he had been a good soldier until August 10, 1983, the date of the Veteran’s first failed drug test, and that was when he knew there was something wrong with him, when he would have been 22 years old. In December 2007, the Veteran reported that he began to experience hallucinations in 1985 and that he sought treatment from a psychiatrist at that time and was placed on medication for six months. Although there are no records to support his statement, his contentions are undermined by subsequent statements that the Veteran was unaware of his problems, which is why he did not seek help for years. When seeking chemical treatment in 1993 and was asked if he had a history of treatment for psychiatric problems, the Veteran reported treatment that year in 1993 and not earlier. The Veteran’s March 2020 claim that he sought treatment for his hallucinations on multiple occasions during service is also not consistent with him not reporting any hallucinatory symptoms for more than 20 years following discharge from active duty, despite evidence of medical treatment on numerous intercurrent occasions while reporting other psychiatric symptoms, such as depression. The Veteran reported seeing a substance abuse counselor during service, but this is not shown in the record. The only counseling statement of record came in October 1983 when the Veteran was “verbally counseled” in reference to the Veteran leaving his duties without permission. The statement does not mention the Veteran’s substance abuse and recommended the Veteran for maximum disciplinary action. The Veteran has also reported varying reasons as to why he stopped working. In 2007 SSA documents, the Veteran indicated that his problems were primarily physical, stating that he worked “until [he] could not work anymore” and his “body could not take it anymore.” However, in May 2010 VA treatment records, the Veteran stated that he had to stop working due to an emotional breakdown, which was not alleged in the SSA documents. The record also shows significant discrepancies over the Veteran’s reports regarding self-harm. On multiple occasions in 1993, the Veteran denied any history of suicide attempt. In April 2015, the Veteran reported “several” suicide attempts via alcohol and drugs while he was in the military, but stated that he “always woke up.” Based on the litany of inconsistent statements throughout the record, the Veteran’s credibility is significantly diminished. Within the context of the Veteran’s diminished credibility, Dr. Cesta’s findings from 2019 and 2020 are less probative. However, there are several contradictions in his report that further suggest that Dr. Cesta’s opinion was based on false factual premises. For example, Dr. Cesta stated that the Veteran has only interacted with his immediate family since his discharge from active duty. The record shows this to be untrue. In July 2007, the Veteran reported regularly going to the library and playing dominoes with cousins and friends “several times per week” until he stopped attending games in 2007 due to concern over marijuana use by other players. In August 2007, the Veteran reported to SSA that he regularly attends church. The Veteran has a long and varied employment history and although his jobs were allegedly derailed by substance abuse, the record reflects the ability to routinely interact with others. The Veteran reported that he goes to the grocery store and does his own shopping. For years, he has participated in group therapy sessions at the VA, where he repeatedly was documented to socialize appropriately; to have good concentration and attention; to follow directions; to demonstrate good problem-solving skills; and to be “very receptive” with normal behavior. He has stated that one of his hobbies is fishing with a friend. Treatment records in July 2011 reflect that the Veteran’s friends took him out for his birthday that year. He has reported living intermittently with girlfriends and children. In January 2017, the Veteran reported that he went on a trip to Tampa with his family, which he enjoyed, and that he was looking into getting a job with Amazon. He has also demonstrated the ability to routinely attend and present appropriately for medical treatment. The preponderance of the evidence is against Dr. Cesta’s assessment that the Veteran created a frightening and unsafe workplace for his fellow employees in his work following service discharge. His characterizations of the Veteran’s social capabilities and functioning are rebutted persistently throughout the longitudinal record. Due to concerns regarding the Veteran’s credibility, the longitudinal treatment records from the time of discharge through 2007 which indicate the absence of psychotic symptoms, are more probative than the Veteran’s and Dr. Cesta’s contention that he simply did not report any symptoms for 20 years, despite presenting for medical evaluation on several occasions in the interim. Additionally, Dr. Cesta stated that, “[e]ven on the dates of my interview, in both 2019 and 2020, he was profoundly psychotic” and suggested that the Veteran would likely require long-term institutionalization within the next several years. He stated that the Veteran’s capacity to communicate, follow instructions, and engage with others appropriately, using correct insight and judgment, are nonexistent. Although Dr. Cesta’s assessment for the Veteran’s future is highly speculative, his statements are not supported by his own examination findings as noted in his 2020 report. Although the Veteran reported symptoms of paranoia and hallucinations on evaluation, Dr. Cesta stated that the Veteran was cooperative and appropriate with fair impulse control. He also found the Veteran’s thought process to be mostly linear and logical. Dr. Cesta found the Veteran cognitively intact and competent to handle his finances. These are not consistent with Dr. Cesta’s indication that the Veteran was profoundly psychotic with a nonexistent capacity to communicate, engage with others appropriately, or use correct insight and judgment. Furthermore, his statements are contradicted by the majority of mental status examinations of record since the Veteran received his 2007 diagnosis, many of which show the Veteran to be fully alert, oriented, and cooperative, with an organized thought process and intact judgment and insight. Dr. Cesta stated that the Veteran was unable to describe or understand the symptoms he was experiencing, which prevented him from being properly diagnosed until 2007. However, this is undermined by the Veteran’s prior statements that he tried to report his hallucinations on multiple occasions during service, but was unable to see a doctor, which would indicate he knew the symptoms he was experiencing. Even though he alleged persistent hallucinations for decades thereafter, the record suggests that he did not report them until 2007. Dr. Cesta’s assessment is also contradicted by the Veteran’s separate reporting of receiving treatment for approximately six months in 1985, during which time he was prescribed psychotropic medication, before discontinuing the treatment on his own accord. Dr. Cesta’s statement that there was no evidence that the Veteran lacked veracity or was a poor historian is discredited by the discussion of the Veteran’s credibility above, and suggests that Dr. Cesta has not fully reviewed the evidence of record. Regardless, determining credibility is for the finder of fact, and the Board makes its own determination on credibility. As to Dr. Cesta’s contention that substance abuse masked the Veteran’s schizophrenia for decades, substance abuse was noted to predate the Veteran’s service. He reported drinking alcohol beginning at age 9 and smoking marijuana beginning at age 13. The Veteran presented for medical treatment on several occasions between discharge from service and 2007 without being noted to be under the influence of any substances and without presenting with any psychotic features, as documented within 1993 VA treatment records, when the Veteran sought treatment for chemical dependence. The preponderance of the substantive evidence is against examiners conflating schizophrenic symptoms with the Veteran’s history of substance abuse, and the Veteran’s treating VA psychiatrist indicated the Veteran has been sober since 2007. Similarly, the April 2020 opinion of the Veteran’s treating psychiatrist relied entirely on the Veteran’s self-reporting of a psychotic break at age 20 in the military, without citing to any evidence of record to support the Veteran’s in-service onset. Opinions based on inaccurate factual premises are not entitled to probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). For these reasons, the opinions of Dr. Cesta and the April 2020 assessment of the Veteran’s treating psychiatrist are not probative. The Veteran has submitted multiple statements from family and friends, wherein they all stated that the Veteran was psychiatrically normal before going into service and was psychiatrically abnormal when he came out of service. They all felt that something happened in service that changed the Veteran. While these individuals appear competent to report observed symptoms, they are consistent with intercurrent causes supported by evidence in the record, such as employment and career difficulties, as well as the Veteran’s history of substance abuse. As stated in the expert opinion of the January 2020 VA examiner, when evaluating complex psychiatric conditions such as schizophrenia, medical records are more likely able to provide specific symptoms reported by professionals that are due to this diagnosis alone (and not due to other etiology). Accordingly, these third-party statements are of little probative value. Alternatively, as the January 2020 VA examiner is an expert who reviewed the evidence of record and provided a through rationale for her conclusions, consistent with the evidence of record, her opinion is most probative. The Veteran was not diagnosed with his current psychiatric disorder of schizophrenia until 2007, and he did not demonstrate psychotic symptoms indicative of such a disorder during service or on medical examination for more than 20 years thereafter. In May 1984, the Veteran specifically denied any changes in his health in the past two years, despite subsequent reports that he attempted to report symptoms of his hallucinations on multiple occasions during this period. While being observed for multiple research studies in the early 1990s, the Veteran was not noted to report or exhibit any psychotic symptoms, including hallucinations. The Veteran had normal findings on psychiatric examination on several additional examinations prior to 2005. As such, the preponderance of the evidence is against a nexus between the Veteran’s current psychiatric disorder and his military service. Additionally, there is no competent and credible evidence that a psychosis was manifested within one year following service discharge, and thus presumptive service connection based on a chronic disease is not warranted. As the preponderance of the evidence is against the claim for service connection for a psychiatric disorder, to include schizophrenia and schizoaffective disorder, 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. § 3.102. 2. Entitlement to a TDIU rating 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). The Veteran is service connected for temporomandibular joint dysfunction (TMJ), residual of mandible fracture at 10 percent. The Veteran is also rated at zero percent for dermatitis of the bilateral feet; a deviated septum, residuals of nasal fracture; and a facial scar of the nose. Thus, the Veteran has a combined rating of 10 percent. The Veteran also has multiple conditions, for which he is not service connected, and, thus, cannot be considered for purposes of the Veteran’s TDIU claim, including the aforementioned psychiatric disorder; arthritis of the left knee; degenerative joint disease of the right wrist; chronic disability of the right hand; right thumb disability; healed right little finger metacarpal fracture; residuals of arthroplasty of the left hallux; chronic bilateral structural foot condition; and presbyopia. 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, 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 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 Veteran’s representative has stated that the Veteran’s TDIU claim cannot be reasonably argued until service connection for schizophrenia is granted. Thus, they requested that the matter of TDIU be remanded for further consideration upon granting service connection for schizophrenia. However, as the Veteran’s claim for service connection for a psychiatric disorder, to include schizophrenia and schizoaffective disorder, has been denied, the Board will proceed with a TDIU analysis relating to his existing service-connected disabilities. The preponderance of the evidence is against a finding that the Veteran has vocational limitations resulting from his service-connected disabilities, or that he has required even routine, recurrent treatment relating thereto. The Veteran underwent a VA examination of his jaw in November 2009. He was found to have some limited range of motion with muscle spasms, and the examiner stated that the Veteran was limited to soft foods. However, on separate VA examination in January 2012, he was found to have full range of motion in the jaw and it was reported that he is able to masticate any and all foodstuffs. Despite some pain and clicking in the jaw, his TMJ was described as mild. In either case, there is no indication that the Veteran’s TMJ has prevented the Veteran from working. Additionally, the totality of the evidence does not show routine treatment for or limitations resulting from the Veteran’s dermatitis, deviated septum, or facial scar. Regarding the Veteran’s education, training, skills, and work history, the Veteran is a high school graduate and reported attending one year of community college for a year and studying psychology. Additionally, the Veteran has stated that he attended Job Corps and studied auto mechanics. The Veteran has also reported past work as a truck driver, janitorial worker, warehouse worker, and cook. Psychosocial rehabilitative treatment records from October 2010 state that the Veteran’s skills include cooking, mechanical work, painting, truck driving, and carpentry. There is no suggestion that these skills are eroded by any service-connected disability. The Veteran’s education, training and varied work history indicate that the Veteran has the capacity for learning and training that would allow the Veteran to resume substantially gainful employment in any of his past areas of work. As stated above, the preponderance of the evidence supports a finding that the Veteran is physically capable of perform substantially gainful employment. His service-connected disabilities are not alleged to have prevented him from performing a diverse range of physically demanding occupations in the past, including his work as a truck driver, janitorial worker, warehouse worker, or cook. Recent medical records predominantly show the Veteran to have a normal gait and full muscle strength. An antalgic gait is noted at times, but only due to non-service connected varus/hallux deformities, and not attributed to the Veteran’s dermatitis, for which he has not required persistent treatment. Records showing that the Veteran has continued to seek employment opportunities continue to support that the Veteran is not unemployable due to physical limitations. In May 2016, the Veteran reported helping his cousin and his cousin’s boss with physically demanding work stripping and waxing floors. In January 2017, the Veteran reported that he was looking into working for Amazon. In February 2020, the Veteran stated that he would like to obtain part-time work in a retail store. The Veteran is able to live independently and manages his own self-care. The weight of the evidence does not indicate the Veteran’s TMJ, deviated septum, dermatitis, or facial scar to cause the Veteran physical limitations that would restrict the Veteran’s ability to perform substantially gainful employment. As to the Veteran’s mental ability to perform substantially gainful employment, the Veteran has no service-connected psychiatric disorder. The Veteran’s service-connected disabilities have not been shown to cause the Veteran communicative deficits. Even when considering nonservice-connected disabilities, psychosocial rehabilitation records reflect the Veteran to have routinely demonstrated good problem solving skills, a focused concentration and attention span, the ability to follow verbal directions, and the ability socialize appropriately and independently. As the Veteran’s service-connected disabilities do not cause the Veteran mental limitations, 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 full-time work that would result in income at the level of substantially gainful employment. For example, the Veteran’s service-connected disabilities would not appear to prevent the Veteran from pursuing his past lines of work as a truck driver, janitorial worker, warehouse worker, or cook. 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 referral for extraschedular consideration of 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 referral for extraschedular consideration of 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.