Citation Nr: 21013578 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 15-28 962 DATE: March 9, 2021 ORDER Entitlement to an initial rating of 50 percent, but not higher, for the appeal period prior to June 20, 2019 for posttraumatic stress disorder (PTSD) is granted. Entitlement to a rating in excess of 70 percent beginning June 20, 2019 for PTSD is denied. Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU) beginning on July 1, 2018, but no earlier, is granted. FINDINGS OF FACT 1. For the appeal period prior to June 20, 2019, the Veteran’s PTSD manifested in occupational and social impairment with reduced reliability and productivity without occupational impairment with deficiencies in most areas or total occupational and social impairment. 2. For the appeal period beginning June 20, 2019, the Veteran’s PTSD manifested in occupational and social impairment with deficiencies in most areas without total occupational and social impairment. 3. The Veteran became eligible for a TDIU in July 2010, the date his claim for an increased rating for his PTSD was received by VA and his employment ended in June 2018. 4. For the appeal period prior to July 1, 2018, the evidence did not show that the Veteran’s service-connected disabilities rendered him unable to obtain and maintain substantially gainful employment due to service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial 50 percent rating for the appeal period prior to June 20, 2019 for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.125, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a rating in excess of 70 percent for the appeal period beginning June 20, 2019 for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.125, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for entitlement to a TDIU as of July 1, 2018, but no earlier, have 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 August 1967 to July 1971, to include service in the Republic of Vietnam. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Newark, New Jersey. In an April 2020 submission from the Veteran’s attorney, the Veteran requested a Board hearing. However, in a July 2020 submission, the Veteran requested that his hearing be cancelled. The hearing request is therefore deemed withdrawn. See 38 C.F.R. § 20.704(e). This case was most recently before the Board in March 2019, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. The case has now been returned to the Board for appellate action. Increased Rating – PTSD The Veteran generally contends that his PTSD symptoms are more severe than contemplated by the rating assigned. Specifically, the Veteran and his attorney assert that his PTSD symptoms more closely approximate occupational and social impairment with deficiencies in most areas, and that such symptoms have been consistent since 2010. See e.g. Third Party Correspondence, July 30, 2020; see also Third Party Correspondence, January 10, 2019. Specifically, in a July 2020 submission, the Veteran’s attorney argues that his PTSD symptoms such as irritability, low frustration tolerance, difficulty in adapting to stressful circumstances, including work or a worklike setting, difficulty in establishing and maintaining effective work and social relationships, disturbances of motivation and mood; flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impaired judgment and impairment of short- and long-term memory warrants a 70 percent rating from July 2010. Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 509–10 (2007). The Veteran’s entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the veteran’s case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Veteran’s PTSD is rated under the General Rating Formula for Psychiatric Disabilities (General 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, 442–43 (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 Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, a 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material; forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted if the disability is productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A schedular maximum 100 percent rating is warranted if the disability ir productive of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. 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 July 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 treatment providers, 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 June 2013 VA examination, the examiner diagnosed PTSD, and opined that PTSD was manifested with occupational and social impairment with reduced reliability and productivity. The Veteran reported that he sometimes struggled with irritable mood and low frustration tolerance at work, but overall, he was able to competently fulfill the functions of his full time employment. The Veteran reported psychiatric treatment with Dr. W.F. on a monthly basis, and denied any history of psychotropic medications, psychiatry visits, or any inpatient or emergency mental health services. Current symptoms included depressed mood, anxiety, suspiciousness, disturbances of motivation and mood; disturbances in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner remarked that the Veteran had consistently experienced symptoms of PTSD that included involving reexperiencing, avoiding and hyperarousal. His functional impairments included disturbed sleep, nightmares, mistrust of others, dislike or avoidance of crowds and group settings, difficulty in social relationships and managing social conflict, low frustration tolerance, reduced senses of self-esteem and self-efficacy, hypervigilance, feeling overly tense and on edge, recurring need to scan surroundings and significant mood disturbance symptoms of depression, anxiety, anger, and irritability. The examiner found the Veteran had significant impairments in social and occupational functioning as a result of his PTSD, but that his psychiatric disability alone did not render him unemployable; and noted that the Veteran currently worked full-time, and considered himself able physically and mentally to continue working full-time. Of record are November 2011, June 2013, and May 2015 private psychiatric treatment records by Dr. W.F. At those times, the Veteran reported he was divorced once, and married for 20 years to his second wife. He had been in a relationship with his current wife for 32 years total. He had one daughter from his previous marriage, but had not seen her since she was three years old; and had three stepdaughters with his second wife. He reported leisure time was spent vacationing in Mexico, woodworking, and boating. He was employed full time by the Township of Marlboro, and he reported having meetings with the mayor, council members, and other political affiliates. The Veteran reported that following his military service, he obtained a commercial driver’s license (CDL) and worked as a truck driver for the same company until 1975; became a fireman and worked as one from 1975 to 1982; and completed the police academy, and worked as an arson investigator for 15 years. He reported he suffered several fire injuries in the 1990s, and was strongly encouraged to apply for disability pension or be fired. He reported feeling bitter about these circumstances and missed his job very much. Subsequently, he remained retired for a little while before working part-time as a building inspector; he eventually started full time and became a supervisor. The Veteran reported he entered in a romantic relationship for 12 years, and had been married for 18 years. He reported occasional irritability and fluctuations in his mood, and described his temper as a “light switch,” but that he had learned to control his temper with age. The Veteran reported having experienced violent nightmares when first separating from active service, but currently he easily fell asleep and experienced a difficult time remaining asleep. He woke up frequently and tossed and turned a great deal in his sleep. Over the course of the past year, disturbing nightmares and distressing dreams had become more frequent and vivid. He reported his relationships with friends and family were generally stable and mutually supportive. He noted increased marital tension through the recent years, and attributed such to his level of tension, irritability, and mood changes. His social network was extensive and stable. Upon mental status examination, the Veteran presented as tense; rigid; generally defensive; speech was clear, distinct, and well-modulated; intellectually bright, with a good command of language and an extensive font of information at times extremely emotional impressing as being tense and irritable, and during these episodes, his thoughts and feelings were expressed more haphazardly and sometimes out of sequence; thought processes logical, coherent, relevant, and goal-oriented; preoccupied with accuracy of the sequence of the events; factual descriptions elaborated, with thoughts and feelings in regard to the memories difficult to verbalize; minimized his experiences; extremely busy schedule with an inability to relax, as an escape from tension and anxiety; ideation of violence towards others, but able to control his feelings and corresponding behaviors; and overly concerned with controlling his hypervigilance. The Veteran reported many of his behaviors and symptoms were distressing to his spouse, and contributory to the marital tensions between them. Dr. W.F. noted the Veteran’s presenting symptoms included more frequent difficulties with sleep patterns, occasional difficulty concentrating, difficulty to attend to work related details and issues, supportive and extensive social network, losing temper more often, inability to express emotions less freely than prior to combat experiences, hyperactivity, hypervigilance, feeling more impatient with others at work, having recent conflicts with supervisors at work, avoiding escalations at work by leaving and going home, expressed a greater level of concern that his temper may become physical, ability to control his temper and impulses to become aggressive decreasing, having more frequent nightmares, intrusive recollections, feelings of irritability and tension, mood swings, and interpersonal conflicts with others at home and work. Dr. W.F. noted that the Veteran proved receptive to learning, practicing, and utilizing cognitive behavioral based strategies to address presenting problems or irritability, tensions and proclivity to overreact to minor events with excessive levels of rage. However, despite his best efforts, the Veteran occasionally found himself becoming “upset and agitated”, and fearing he will experience more difficulties controlling and regulating his thoughts and behaviors. He maintained a high level of guardedness and suspiciousness around others, had feelings of anger and rage that were easily triggered, overreacted disproportionally to slight triggers when confronted at work and home, continued to struggle with interactions at work with supervisors and co-workers, continued to experience marital tensions causing a “see-saw” relationship, had a lack of patience, and level of irritability and general level of tension that was a prominent factor in all of his negative interactions with others. Dr. W.F. summarized that the Veteran tended to minimize and discount the intensity, severity, and level of disruption resulting from his psychological, emotional, and/or physical difficulties; consistently maintained participation in individual counseling since November 2011; consistently impressed as being positively motivated to benefit from his participation; readily attempted to learn, utilize, and incorporate all treatment suggestions and recommendations provided; and despite his best efforts to modify his thoughts and behavioral processes, continued to impress as struggling in all of his interpersonal interactions with others. Of record is a February 2018 private psychiatric evaluation by Dr. J.S. At this time, Dr. J.S. noted the Veteran expended constant effort trying to re-experience his traumatic in-service stressors and associated PTSD symptoms; used work as a therapeutic escape from intense memories and anxiety, which were at a heightened risk of resurfacing when alone at home; then having to escape from work when he loses control of his anger, which was triggered from being around others. The Veteran reported he worked full time as a building inspector, with the same employer since August 1999 and had been suspended due to his paranoia and interactions with others. The Veteran reported he had been counseled several times for his interactions with coworkers, and that he would grab his jacket and leave due to fear of doing things he would regret. He had extended periods of not working, lasting six weeks to two months in duration. However, despite this “pattern of grossly ineffective and inappropriate behavior, the [V]eteran notes that his long-term employer ‘has been very lenient with me,’” and acknowledged that his employer was more lenient with him as compared to others. Therefore, Dr. J.S. found the Veteran had essentially been in a sheltered work position by long-term employers who treated and managed him very differently from his co-workers, such that he would have otherwise been fired for his angry and avoidance behaviors and his extended and sudden leaves of absence due to his PTSD. Dr. J.S. noted that the Veteran demonstrated poor focus, concentration, and memory throughout the evaluation, such that instructions had to be repeated four times on one occasion, indicating that his PTSD would have been markedly impairing his actual job performance even when he was physical present on his job. Dr. J.S. opined that the Veteran’s PTSD had been moderately severe from 2010 to 2015, and more severe from at least 2015 when his wife died to the present; and that his PTSD caused him to be unable to secure or follow a substantially gainful occupation outside of a sheltered employment from at least 2015 to the present. Upon mental status examination, Dr. J.S. noted the Veteran presented with average grooming and hygiene, was oriented to person, place, and time, had mood generally flat and detached and used humor at times as an emotional defense. The provider noted there was a stark intensity of mood which was always just under the surface, that there was a pattern of extreme over-control of emotion as a means of coping; affect appropriate to mood, that there was a persistent and unshakable paranoid sense that others were lying, could not be trusted, out to get him, or a threat and danger to him, that there was a persistent fear of losing control and reacting aggressively toward others and that the Veteran was grossly uncomfortable in his own skin when around others, due to the constant fight against disturbing and potentially overwhelming intrusions from combat experiences. The Veteran reported sleep that was short and interrupted, with restlessness, waking up, inability to go back to sleep, and averaging 4 to 4.5 hours of sleep per night. He described his appetite as “better” after losing his appetite previously. His energy would “fade” in the afternoon, feeling exhausted, and feeling fatigue due to his sleep disturbance. He described difficulty with focus and concentration. He reported memory problems had existed for so long that it felt “normal.” He reported paranoia that was described as distrust of others, and having to watch the front door. His social activity was “minimal” after his wife passed away. He reported primarily solitary activities for recreation. His occupational activity was impacted his lack of patience at work. During his clinical interview in February 2018, the Veteran reported difficulty at work due to distrust of others and a lack of patience and difficulty with interactions with his supervisors and coworkers. PTSD symptoms included disturbing memories, flashbacks, nightmares, emotional and physical distress when reminded of stressful in-service experiences, expending constant effort to avoid thinking about and being reminded of stressful combat experiences, loss of interest in things he used to enjoy’ feeling estranged, feeling emotionally numb and feelings of a foreshortened future. Other symptoms included troubling falling and staying asleep, which was “extremely disturbing” to the Veteran, irritability, angry outbursts, aggressive outbursts, difficulty concentrating, being “super alert,” being on guard all the time, constant paranoia, a heightened startle reaction and distancing from others. Dr. J.S. noted the Veteran demonstrated highly impaired focus, concentration, and memory; and clinical testing indicated PTSD symptoms were at a consistently high intensity with an extended to constant duration. Additionally, Dr. J.S. found the Veteran had a significant degree of impairment in: cognition, extreme difficulty with concentration and remembering; getting around, chronic daily cycles of compulsively busy behavior and then anergia secondary to his PTSD, which was a source of concern or distress; self-care, severe with improved issues around eating, and staying to himself; getting along, extreme difficulty getting along with strangers and maintaining friendships; life activities, daily cycles of compulsively busy behavior and anergia significantly interfere with the demands of running a household, indicating significant general impairment on this domain, and not working in a “setting outside of a sheltered environment for years,”; participation, extreme difficulty joining community activities as others, such as festivities or religious activities, and problems with family. The Veteran stated he preferred to do things alone. Dr. J.S. opined that the Veteran’s PTSD symptoms had been at least moderately severe from 2010 to 2015, indicated by his struggles with work, and was experiencing reduced reliability and productivity; and beginning in 2015, his PTSD was manifested with occupational and social impairment with deficiencies in most areas. Dr. J.S. noted the June 2013 VA examination report, and found the Veteran’s avoidance-based minimization of symptoms could cause any evaluator to underappreciate the true severity and impact of his PTSD, and found his symptoms showed a public risk associated with working with others and his avoidance behaviors. With regard to employability, Dr. J.S. opined the Veteran’s PTSD caused him to be unable to secure or follow a substantially gainful occupation outside of a sheltered employment from at least 2015 to the present. In this regard, Dr. J.S. opined that the Veteran’s long-term employer further loosened their demands and expectations of the Veteran, and increased their leniency regarding his ineffective work process and work relationships due to his combat history and long employment with them, as well as the recent death of his wife. As such, Dr. J.S. opined that he had been operating in a sheltered work environment provided by his long-term employer that was demonstrated by treating and managing the Veteran differently from his co-workers, such that, other employees would have been fired. Dr. J.S. opined that the Veteran was well intentioned, but could not be successful in any public or private setting outside of a sheltered work environment; and that his continued sheltered-employee involvement created significant personal and public safety risks. Dr. J.S. summarized that these severe limitations rendered this Veteran fully incapable of security or following a substantially gainful employment, including jobs requiring non-exertion activities, such as communicating, remembering, following instructions, using judgment, adapting to change, and dealing appropriately with others; and that the Veteran was not employable in any occupation. At a July 12, 2019 VA examination, the examiner opined the Veteran’s PTSD manifested with occupational and social impairment with reduced reliability and productivity. The Veteran reported he tried dating after his wife died in 2015, but dating was not enjoyable. He described his relationships with his daughter and two step-daughters as “perfect,” and that he had “awesome” relationships with his grandchildren. He reported he had been close with his older sister, traveling with her regularly, but recently had become distant because she was not understanding over losing his wife, or with his relationships with his stepdaughters. He described his relationship with his other sister as “fine.” He had some friends, including through his membership at the Elk Club, and went to the club once a month. He reported he liked to stay occupied and preferred to stay alone. He did woodworking, painted his house, updated his house, took five mile walks on the boardwalk about two to four times a month for recreation. He reported he continued in the same job, would go to work early due to sleep problems, and work extra hours; and his employer did not like this. The Veteran reported he was also verbally aggressive, and in the last two years he had been written up for how he spoke to others, and was suspended in December 2017. The Veteran stopped working in June 2018. During this interview, the Veteran reported he began having somatic symptoms associated with stress beginning in September 2017; increased stress intensified his sleep disturbance, panic attacks, including during at night and had continued psychiatric treatment. The July 2019 VA examiner determined that symptoms attributable to his PTSD included depressed mood, anxiety, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment and mild memory loss, such as forgetting names, directions or recent events. Other symptoms were noted to include impaired judgment, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting and impaired impulse control, such as unprovoked irritability with periods of violence. Behavioral observations showed the Veteran was open and cooperative, that his speech within normal limits for rate and articulation, that his thought processes clear, coherent, and goal-directed and that there was no evidence of delusions. The Veteran denied auditory and visual hallucinations as well as suicidal and homicidal ideations. Mood described as somber, mildly depressed and anxious, he was noted to be tearful on occasion, affect was broad and appropriate and sleep disturbance reported, with frequent and early morning awakening, and sleeping 4 to 4.5 hours a night. Intermittent decreased appetite with associated weight loss and short-term memory impairment were reported and fair judgment and fair insight were found. The examiner remarked that the Veteran’s ability to function in an occupational setting is impaired by his PTSD symptoms as follows: moderate cognitive difficulties which would interfere with completing work tasks accurately and efficiently; moderately impaired socially; isolating to a significant degree and prone to being irritable, which would interfere with his ability to interact with supervisors and coworkers appropriately and without undue distress; intensified levels of stress and becoming verbally aggressive at work when he was previously employed; and sleep disturbance and regular panic attacks likely to interfere with attendance and quality of work performance. Overall, the examiner noted the Veteran’s occupational functioning was severely impaired as a result of his PTSD. Of record is an August 2019 private psychiatric treatment record by Dr. W.F. The Board notes the August 2019 treatment record is essentially identical to the November 2011, June 2013, and May 2015 private psychiatric treatment records with only a few minor variances. Notably, the Board notes the treatment record indicates the Veteran’s wife passed away, but is identical to prior evaluation reports when describing his marital relationship and tensions. In pertinent part, the August 2019 private psychiatric treatment record indicates the Veteran’s wife died in August 2015; he retired from his job in June 2018; and noted the Veteran impressed as being permanently and totally disabled from gainful employment. Of record is an April 2020 private vocational assessment by P.M. At this time, P.M. noted the Veteran was precluded from employment due to his PTSD and prostate cancer residuals due to symptoms related to sleeping well throughout the night, controlling his emotions due to significant irritability, adapting to and maintaining composure in stressful situations, establishing and maintaining effective work and social relationships; concentrating and staying on task; performing any movement without experiencing urine leakage, the need for excessive breaks to change pads, or need to be in close proximity to the restroom. The Veteran reported that his PTSD and urinary incontinence, and all related symptoms, affected him while working and continue to affect him on a daily basis, to include at work. According to the Veteran, his activities of daily living were impacted by his PTSD and related depression due to inability to care for his personal hygiene while working as a building inspector; not showering or shaving regularly without the encouragement of his wife; and an increase of neglect of personal hygiene after his wife died. During the April 2020 private vocational assessment, the Veteran reported he received a high school diploma, and attended two years of college but did not receive a higher degree. His employment history included working as a firefighter for 23 years, and retiring from a shoulder injury; and working as a home building inspector beginning in 1999. Beginning in 2008, he stated his relationship with the new administration worsened and became incompatible; and was consistently in disagreement with the township administrator and was being “chewed out for everything.” He stated his PTSD interfered with his ability to work, and worsened in 2010 due to the pressures of the job exacerbating his symptoms. He expressed difficulty getting along with others, frustration with his expectations of professionalism, increased anxiety and difficulty being around others, and would take days off work four to five times a month. He stated he needed a lot of “mental time outs,” reported “rocking the boat,” and getting away with excessive breaks, numerous absences, and mistakes on the job due to not having direct supervision or anyone overseeing his daily behavior. During the April 2020 private vocational assessment, the Veteran reported chronic sleep disturbance for over 50 years, with worsening sleep in 2008. Notably, he reported working 12 hours and staying on the phone with his office manager to stay awake while driving. He reported significant fatigue and lack of sleep resulted in falling asleep while driving on different occasions. He reported depression impacted his work because he would neglect his hygiene for days until his wife would make him shower or shave. He reported needing mental breaks and would take off of work for days when he did not want to work. In 2016, he stated he could not take the pressures of the job, was falling behind, became more confrontational, made derogatory and rude remarks to others, became more argumentative, and had numerous meetings to discuss his inappropriate behavior. He reported many warnings were given. With regard to hypervigilance, the Veteran reported that beginning in 2010, he could not tolerate being in crowds; and being in crowds would cause him to be “extra hypervigilant and anxious.” He reported choosing to work late into the night or taking excessive breaks in the workday to avoid large crowds. He also stated he would give up in the middle of a task at work due to stress. The Veteran reported urinary incontinence impacted his ability to work because it would be disruptive to his workday. During the April 2020 private vocational assessment, the Veteran reported that beginning in November 2017, his PTSD symptoms were “getting out of control,” and that he attended meetings to discuss his inappropriate behavior and disrespectful treatment of others and he was suspended from work for a period of time. He related his argumentative and rude behavior as a direct result of the PTSD, stress and interference with daily functioning. He stated the township administrator gave him “special treatment” because he was a veteran but was told that he would have been fired in a typical work environment. He stopped working in June 2018 due to the continued interference of his PTSD symptoms that affected completion of job duties in a reliable and consistent basis. P.M. opined that the Veteran’s PTSD, urinary incontinence, and related symptoms that included concentration difficulties, anxiety, hypervigilance, anger, need for excessive breaks, and avoidance behaviors precluded him from being employed in any work setting. P.M. noted the Veteran had perseverance, commitment, and dedication. However, he was limited by his educational background and symptoms of anxiety, depression, reclusive behavior, difficulty forming and maintaining work and social relationships, inability to concentrate and focus well, angry outbursts, significant irritability, flashbacks, nightmares, interrupted sleep, difficulty trusting others, hypervigilance, limited attendance of social activities, due to embarrassment of unpredictable need to urinate, hypervigilance, and social anxiety in public settings, going out in public without the need to be in close proximity to a bathroom and sitting, standing, or walking for prolonged periods without the urge to urinate or the need for excessive breaks to change pads (at least eight to 10 times during a workday). P.M. found that the Veteran’s inefficiency was apparent as he had significantly slower work productivity as demonstrated by his working late into the night and missing important deadlines, had an inability to focus resulted in numerous mistakes, excessive breaks, and help from coworkers and had numerous counseling meetings with his supervisors regarding his behavior. P.M. found the Veteran’s ability to be considered a reliable employee would be significantly reduced due to his near-continuous state of panic, combined with anger and isolation. Additionally, P.M. noted the Veteran’s disturbance of personal hygiene maintenance, disturbances of motivation and mood, and urinary incontinence shows the Veteran is unreliable and unable to perform any work. P.M. noted that the Veteran’s work from 2010 to 2018 was highly accommodated and would not be considered a typical work environment for “many reasons.” P.M. further noted the Veteran’s sleep impairment would significantly impact his ability to work due to decreased concertation and fatigue. P.M. also noted the Veteran’s urinary incontinence would impact his ability to work due to interruptions to change his pads and relieve himself, and that it was a significant barrier to active and sedentary occupations preventing work. P.M. noted the Veteran’s cognition, pace, interpersonal functioning, stress, persistence, conscientiousness and motivation, and reliability would prevent him from working in an efficient and consistent manner. Overall, P.M. concluded and opined that the Veteran’s PTSD and urinary incontinence would preclude him from being able to perform essential work functions of his past work or any competitive job, from July 27, 2010 to the present. Further review of the record shows that the Veteran receives treatment from private treatment providers for various disabilities, to include his PTSD. However, there is no indication from the treatment notes of record that the Veteran has reported mental health symptoms that are worse than those noted above. Based on the foregoing, the Board finds that an initial 50 percent rating for the appeal period prior to June 20, 2019 is warranted and a rating in excess of 70 percent thereafter for PTSD is not warranted. In this regard, the Board finds that such disability was manifested by occupational and social impairment with reduced reliability and productivity for the appeal period prior to June 20, 2019 and occupational social impairment with deficiencies in most areas for the appeal period thereafter. For the appeal period prior to June 20, 2019, the Veteran’s PTSD manifested in occupational and social impairment with reduced reliability and productivity, without occupational and social impairment and deficiencies in most areas. In this regard, the Veteran showed social impairment due to symptoms such as depressed mood, anxiety, suspiciousness, disturbances of motivation and mood, disturbances in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a worklike setting. Additionally, the Veteran presented with symptoms that included reexperiencing, avoidance, hyperarousal, chronically disturbed sleep, nightmares, mistrust of others, dislike or avoidance of crowds and group settings, difficulty in social relationships and managing social conflict, low frustration tolerance, reduced senses of self-esteem and self-efficacy, hypervigilance, feeling overly tense and on edge, recurring need to scan surroundings and significant mood disturbance symptoms of depression, anxiety, anger, and irritability. The Veteran reported he preferred to be alone, did not have a relationship with his daughter, and had some marital tension as a result of his PTSD symptoms. However, the Veteran consistently reported he was married until his wife’s death in 2015, that his relationships with friends and family were stable and mutually supportive, and had a good relationship with his stepdaughters and other family members. Notably, at a July 2019 VA examination, the Veteran reported that he used to travel regularly with his older sister prior to his wife’s death in 2015. Additionally, the Veteran consistently reported that his spouse was a good support system. Moreover, Dr. W.F. noted the Veteran consistently presented as receptive to learning, practicing, and utilizing coping skills and strategies, and consistently maintained motivation to benefit from his participation in psychiatric therapy. The Veteran also reported he learned to control his emotions and temper with age. With regard to occupational impairment, the Veteran demonstrated some impairment due to symptoms such as angry outbursts, impatience, irritability, fluctuations in mood, distrust of others, anxiety, panic attacks, difficulty in crowds, sleep disturbance and daytime fatigue and difficulty with concentration and focus. In this regard, the Veteran was shown to have difficulty with interactions with his coworkers and supervisors, some warnings being issued at work regarding his inappropriate behavior, and interpersonal conflicts. However, the Veteran maintained full-time employment with one employer for 16 years until 2018. His employment required meetings with the mayor, council members, other political affiliates, and the general public. Additionally, the June 2013 VA examiner found that his psychiatric disability alone did not render him unemployable, and the Veteran himself considered himself able to physically and mentally continue working full-time. Although the Veteran reported increased irritability, tension, mood swings, and interpersonal conflicts, he also reported at a February 2018 private psychiatric evaluation that he used work as a therapeutic escape from his PTSD symptoms. Moreover, the February 2018 private opinion from Dr. J.S. noted that the Veteran had some occupational impairment due to PTSD, and described such impairment as “moderately severe,” prior to 2015 and “severe” thereafter. Dr. J.S. summarized that these severe limitations rendered this Veteran fully incapable of security or following a substantially gainful employment, including jobs requiring non-exertion activities, such as communicating, remembering, following instructions, using judgment, adapting to change, and dealing appropriately with others and that the Veteran was not employable in any occupation. The Board also notes the Veteran reported being suspended at work for a short time due to his PTSD symptoms in 2017. However, the Veteran returned to work thereafter. Additionally, the Veteran himself asserts that his unemployability is not solely as a result of his PTSD, but also in combination with physical disabilities. No impairment to thinking was demonstrated. Judgment was not impaired as it was consistently found to be intact or good during the appeal period. School was not attempted during the appeal period. Therefore, the Board finds that the Veteran’s PTSD manifests as occupational and social impairment with reduced reliability and productivity and without occupational and social impairment with deficiencies in most areas prior to June 20, 2019. Moreover, 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 period on appeal. In that regard, 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 has reported some violent ideation toward others but has consistently denied any suicidal or homicidal ideations. Homicidal or suicidal attempts were never attempted or started. Moreover, there is no evidence that the Veteran has experienced hallucinations or delusions, or obsessive rituals. Further, the Veteran 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. Notably, the Veteran reported some disturbance of hygiene, such that he would not shave or shower for a few days. However, mental status examinations during the appeal period consistently found the Veteran’s grooming and hygiene to be appropriate or adequate. 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. Additionally, the Veteran reported that he had worsening PTSD symptoms beginning 2017, but that he continued to work until June 2018, but that his unemployment was due to a combination of his PTSD and prostate cancer residuals. Additionally, the July 2019 VA examiner noted the Veteran had significant impairment of occupational functioning, but such impairment was not total. Further, the Veteran reported he had a “perfect” relationship with his daughter and stepdaughters, an “awesome” relationship with his grandchildren, attempted dating after his wife passed away in 2015, and had friends with regular social interaction at the Elk Club on a monthly basis. Therefore, this is not a disability picture indicating total occupational and social impairment at any time during the appeal period. In assessing the severity of his PTSD, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board notes the contentions of the Veteran and his attorney that his PTSD is more severe than currently shown on examination; and the Board observes that the Veteran, while he was competent to report his observable symptoms, was not competent to report that the his mental health symptoms were of sufficient severity to warrant a higher rating under VA’s tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). Despite the foregoing, the Board acknowledges the Veteran’s attorney’s assertions that the Veteran’s various symptoms and functional impairments warrant a 70 percent rating from July 2010. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher rating are not met. See Lendenmann, supra. 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 additional staged ratings under Hart, supra is appropriate; however, the Board finds that his symptomatology was been stable throughout each period on appeal. Therefore, assigning additional staged ratings is not warranted. The Veteran nor his representative have 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 the preponderance of the evidence is for the assignment of an initial 50 percent rating for the appeal period prior to June 20, 2019 and against the assignment of a rating in excess of 70 percent thereafter for PTSD. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Entitlement to a TDIU Prior to June 20, 2019 The Veteran asserts he is entitled to a TDIU prior to June 20, 2019, the day he submitted an application for a TDIU to VA. Specifically, the Veteran and his attorney assert that the Veteran’s employment from 2010 to 2019 qualified as sheltered employment, and therefore he did not maintain substantially gainful employment since at least 2010. See Third Party Correspondence, July 21, 2020. Specifically, his attorney argues that the Veteran was allowed excessive breaks, numerous extended absences, mistakes on the job, and leniency not afforded to others; and the Veteran was unable to secure and maintain substantially gainful employment from 2010 as a result of his PTSD and prostate cancer residuals. Id. 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). The Board is mindful that under 38 C.F.R. § 4.16(a), marginal employment shall not be considered substantially gainful employment. Marginal employment shall be found if a veteran’s income does not exceed the poverty threshold established by the United States Census Bureau or, when income does exceed the poverty threshold, it may be shown on a facts found basis, which includes, but is not limited to, employment in a protected environment. Id.; Ortiz-Valles v. McDonald, 28 Vet. App. 65, 71 (2016). Although VA has not defined what constitutes work “in a protected environment,” the Board nevertheless must consider its applicability on a facts found basis. “Substantially gainful employment” is defined as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran’s earned annual income. See Faust v. West, 13 Vet. App. 342 (2000). The central inquiry in determining whether a veteran is entitled to TDIU is whether a veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability. See Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993). The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-32 (1991). 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). In the instant case, as of the date of this decision, prior to June 20, 2019, the Veteran was service-connected for PTSD, now rated as 70 percent from July 27, 2010; residuals of prostate cancer, rated as 60 percent from July 27, 2010; tinnitus associated with hearing loss, rated as 10 percent from October 17, 2011; inactive chronic duodenal ulcer, rated as noncompensable from December 16, 1975; erectile dysfunction, rated as noncompensable from July 27, 2010; and hearing loss, rated as noncompensable from October 17, 2011. Thus, the schedular criteria for TDIU have been met prior to June 20, 2019. 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 prior to Jun 20, 2019. The record shows that the highest level of education attained by the Veteran is high school with two years of college and he obtained a CDL. His employment history is described in the preceding section and incorporated herein. During service, the Veteran’s military occupational specialty (MOS) included water transport. Thereafter, the record shows that the Veteran last worked in June 2018 as a building inspector. 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). The Board notes the psychiatric treatment records and evaluations as noted in the preceding section, and the Board’s determination of the Veteran’s claim for an increased rating for his service-connected PTSD as discussed above and incorporates such herein. In addition, turning to the evidence, at a September 2010 VA examination for the Veteran’s prostate cancer, the examiner noted there were no significant effects of prostate cancer residuals on his usual occupation and that the Veteran required daily protection. Additionally, the examiner noted there were no effects from the residuals of prostate cancer on the Veteran’s usual daily activities. At a June 2012 VA audiological examination, the examiner noted that the Veteran’s bilateral hearing loss impacted his ability to work due to difficulty hearing, and having to talk loudly, and to have the television and radio loud. The examiner noted that the Veteran’s tinnitus did not impact his ability to work. At a June 2013 VA examination for the Veteran’s prostate cancer, the examiner noted that prostate cancer residuals impacted his ability to work due to leaking urine, urinary incontinence and found such symptoms as a significant barrier to active or sedentary occupation. The examiner noted the Veteran would be unable to work at all. In support of his claim, the Veteran submitted a VA form 21-8940 Veterans Application for Increased Compensation Based on Unemployability, and indicated that his PTSD prevented him from securing or following any substantially gainful employment from 2010 to the present. The Veteran reported he last worked in June 2018, and worked 35 hours a week at this job from August 1999 to June 2018. He reported the most he earned in one year was $198,147.00 in 2017. As an initial matter, the Board notes that the Veteran was awarded a TDIU in a March 2020 rating decision, effective June 20, 2019. This is the date that a formal claim for a TDIU was received by VA. However, the record reveals that the Veteran’s employment ended sometime in June 2018 and that he has been unemployed since July 1, 2018. In Rice v. Shinseki, the Court explained that a request for a TDIU is not always a separate claim, as follows: a request for TDIU, whether expressly raised by the veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, whether as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for an increased rating. Rice v. Shinseki, 22 Vet. App. 447, 453, 54 (2009). In the instant case, the Veteran's claim for TDIU arose as part of his claim for an increase for his PTSD. Therefore, entitlement to a TDIU arose as of July 1, 2018. To that extent, the appeal is granted. However, the Board finds that the Veteran is not entitled to a TDIU prior to July 1, 2018. The Board has carefully considered the Veteran’s statements regarding the effects of the Veteran’s service connected PTSD with residuals of prostate cancer on his employability. Although the Veteran experienced some limitations as a result of his service-connected disabilities, and these have been found to cause some impact on his daily functioning and earning capacity, that impact was considered in the scheduler ratings currently assigned. Simply stated, if he did not have impairment with his service connected PTSD and prostate cancer residuals, there would be no basis for the combined rating prior to June 20, 2019. The fact that he was having impairments or difficulties does not provide a basis to grant TDIU. Further, the Veteran himself asserted that he believed he could continue to work full-time, and maintained full-time employment until June 2018. The Board notes that the Veteran was employed until June 2018 as a building inspector and had remained employed full-time with the same employer beginning in 1999. Specifically, at his June 2013 VA examination, the Veteran reported that he worked full-time and considered himself able to physical and mentally to continue working full-time. His employment history is notable that the Veteran maintained long-term regular employment with three employers over the five decades following separation from active service. He worked for four years as a truck driver, seven years as a fireman, and then 16 years as a building inspector until 2018. Additionally, the Board notes the private evaluations by Dr. W.F., Dr. J.S. and P.M. that the Veteran was unemployable as a result of his PTSD and residuals of prostate cancer. Specifically, Dr. W.F. noted his PTSD symptoms resulted in interpersonal conflicts at work and home, and he struggled with irritability, frustration, and rage. Dr. J.S. specifically noted the Veteran had been suspended due to paranoia and his interactions with others; had extended periods of not working; would leave; and that the Veteran had essentially been employed in a sheltered work position. P.M. opined that the Veteran was precluded from employment due to his PTSD and prostate cancer residuals, and that such symptoms precluded him from being able to perform essential work functions of any job from July 2010 to the present. The Board also notes that the June 2013 VA examiner found the Veteran’s prostate cancer would impact his ability to work, and was a significant barrier for occupation and that the Veteran would not be able to work at all. However, the Veteran was able to secure and follow a substantially gainful occupation. In this regard, the Veteran was substantially and regularly employed for the entire period beginning until June 2018, and was able to earn more than the poverty threshold for each year that he was employed; without any gaps in employment whatsoever. 38 C.F.R. § 4.16(a) (directing that marginal employment will be deemed to exist when earned income does not exceed the poverty threshold). Thus, the Board finds that his employment as a building inspector, as reported by the Veteran, was substantially gainful (i.e. not marginal). Moreover, the Board notes that the Veteran himself asserts that he is capable of employment; and throughout the period on appeal, the Veteran maintained employment and stayed with each employer for many years. Although the Veteran’s tax income data is unavailable, there is no evidence to show that his annual income fell below the poverty threshold as determined by the United States Department of Commerce, Bureau of the Census. Notably, the Veteran himself reported he had an income of $198,147.00 in 2017. Marginal employment may also be held to exist, on a facts found basis that includes, but is not limited to, employment in a protected environment such as a family business or sheltered workshop when earned annual income exceeds the poverty threshold. Here, the evidence does not establish, and the Veteran has not alleged, that such employment was a family business or sheltered workshop or that such employment was for physically disabled or mentally handicapped adults. Although the Veteran and his attorney assert that his employment was precluded due to his mental health symptoms, and the Veteran is actually unemployable, the evidence demonstrates otherwise. In this regard, the Board notes the Veteran was able to maintain regular employment for many consecutive years and earned an income well above the poverty threshold. The Veteran also maintained regular employment requiring 35 hours of work on a weekly basis. Accordingly, the Board finds that considering the facts of this case, to include the hours of employment, the skills required, and the salaries provided, it is not established that the Veteran’s employment was marginal employment. To the extent that the Veteran contends his employment was sheltered employment, the Board finds that it was not. The Board observes that the examples of “protected environment” used in the text of 38 C.F.R. § 4.16(a): the family business and sheltered workshop. The term “sheltered workshop” is not defined in title 38 of the Code of Federal Regulations, but several state codes define “sheltered workshop” in the following ways: “a facility designed to provide gainful employment for individuals with severe disabilities who cannot be absorbed into the competitive labor market or to provide interim employment for such individuals when employment opportunities for them in the competitive labor market do not exist” (Louisiana); “a facility, or any portion thereof, operated by a nonprofit organization, corporation, partnership, limited liability company or association whose purpose is to provide meaningful work or training activities to individuals with developmental disabilities....” (Oklahoma); “an occupation-oriented facility operated by a not-for-profit corporation, which, except for its staff, employs only persons with disabilities” (Missouri); “an occupation-oriented facility operated by a nonprofit agency, public or private, which except for its staff, employs only handicapped persons” (New Jersey). La. R.S. § 39:1604.4; 63 Okl. St. § 1-865.2; § 178.900 R.S.Mo.; N.J. Stat. § 34:16-40. In this case, the Veteran’s post-service employment worked for a local government and such employment was not provided to him to as a result of his disabilities nor because competitive labor market employment did not exist. Rather, the Veteran worked a building inspector, a highly skilled professional position for which he received a salary of nearly $200,000.00 in 2017. The Veteran himself reported that he did receive consequences for his behavior at work in that he was counseled for his inappropriate behaviors, given warnings for his conduct, and eventually terminated. Moreover, the Board notes the contentions of the Veteran’s attorney that his psychiatric symptoms resulted in being prevented from maintaining gainful employment that warrants entitlement of a TDIU. However, as discussed above, the Veteran did indeed maintain regular employment in a highly skilled occupation and earned income that far exceeded the poverty threshold. The regulations do not consider whether a veteran is able to obtain and maintain gainful employment for which he is performing at an exceptional or even satisfactory level; rather, the regulations consider whether a veteran was unable to obtain and maintain gainful employment only. The Board notes the arguments of the Veteran’s attorney that the accommodations such as unexcused absences and excessive time off provided to the Veteran rendered the Veteran’s employment a sheltered environment. Moreover, the Board also notes the Court’s holdings in Cantrell v. Shulkin, 28 Vet. App. 382 (2017). The findings of Judge Lance in the concurrence are particularly persuasive in that such an interpretation as suggested by the Veteran’s attorney is inconsistent with the statutory purpose of compensating veterans for the impairment in earning capacity associated with their service-connected disabilities, because an accommodation necessarily prevents the disabled employee from losing the income associated with his or her employment. Id. at 394 ("If a claimant's disabilities do not result in lost income, then there is no loss of earning capacity, and an award of TDIU would not be appropriate.") (Lance, J., concurring). As Judge Lance also suggested, the accommodation-based definition suggested in the employment evaluation examiner's report is in tension with a complex system of laws and regulations prohibiting discrimination in employment against persons with disabilities. These laws apply to disabled persons generally, and so necessarily protect many veterans. The premise behind much of that legislation is that many disabled persons can be gainfully, and successfully, employed when their employers provide reasonable accommodations. Moreover, the Board agrees with Judge Lance that, "[w]here a claimant's employer is required by law to provide reasonable accommodations pursuant to the [ADA] and those accommodations allow the claimant to engage in a substantially gainful occupation, a TDIU award would, in effect, constitute a second paycheck on the back of the taxpayer." Id. at 394. In applying the above principles to the facts of this case, the Board finds that the Veteran's previous employment as a building inspector would not be considered "employment in a protected environment" as the term is used in 38 C.F.R. § 4.16(a). This is so because there is no evidence that purpose of the Veteran's local government employer is to hire people with disabilities to train or rehabilitate them; in short and there is no evidence that the Veteran is currently employed for a charitable or therapeutic purpose. There is no evidence that the purpose of the Veteran's employer is to provide employment to disabled workers. As discussed in Cantrell, the Veteran's disabilities do not result in lost income and legally required accommodations permit him to maintain gainful employment; the fact that the Veteran's employer approved multiple accommodations or may have made additional accommodations above and beyond what they are required to do by law is not persuasive. To reiterate, the Board and the Court in Cantrell have rejected an accommodation-based definition of a protected work environment. This argument is therefore without merit. The Board acknowledges that the Veteran is competent to report the symptoms of his disabilities. Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). The Board recognizes that the Veteran has stated that he had problems with cognitive difficulties, psychiatric symptoms, and physical limitations. The evidence, however, shows that the Veteran is not unable to obtain and maintain employment due to his service-connected disabilities. Based on the foregoing, and in consideration of the pertinent medical findings, including his reports at the various VA examinations of record and during treatment at VA medical centers, where he indicated his barriers to employment included problems getting along with others; difficulty with urinary incontinence, and other psychiatric symptoms, the Board finds that the Veteran is not unable to secure and follow a substantially gainful occupation by reason of his service connected disabilities. In this regard, as discussed in the preceding section, the Veteran’s PTSD has been found to result in, at most, occupational and social impairment with reduced reliability and productivity prior to July 1, 2018. Thus, such disability is not shown to render the Veteran unable to secure or follow a substantially gainful occupation. Moreover, the Veteran’s prostate cancer residuals have been rated as 60 percent disabling, and as noted above, the problems form the basis of the evaluation assigned. Additionally, the Veteran does not assert that his other service-connected disabilities impacted his ability to work, and the functional impairment related to his other disabilities are not for consideration. Therefore, based on the foregoing, the Board finds that, while the Veteran’s PTSD and prostate cancer residuals results in some impairment in occupational functioning, which is represented by his currently ratings assigned, and such disabilities do not render him unable to secure or follow a substantially gainful occupation. Further, as noted above, the Veteran maintained regular full time employment until June 2018; and earned far above the poverty threshold; and such employment was not marginal nor sheltered or protected employment. Additionally, as noted above, the Veteran’s psychiatric symptoms were stable within each applicable period upon appeal, and has manifested in occupational and social impairment in reduced reliability. Therefore, the Board finds that entitlement to a TDIU is warranted as of July 1, 2018. However, the Board finds that the Veteran’s service-connected disabilities do not render him unable to secure and follow a substantially gainful occupation prior to July 1, 2018. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and entitlement to a TDIU is not warranted. 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 Mariah N. Sim, 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.