Citation Nr: 21024157 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 11-33 716 DATE: April 22, 2021 ORDER Entitlement to a 20 percent, but no higher, rating for a left knee gunshot wound disability is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a 50 percent, but no higher, rating for an unspecified anxiety disorder with major depressive disorder prior to August 3, 2012 is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a rating in excess of 50 percent for an unspecified anxiety disorder with major depressive disorder from August 3, 2012 is denied. Entitlement to a rating in excess of 70 percent for an unspecified anxiety disorder with major depressive disorder from May 23, 2016 is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied.  FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s left knee gunshot wound disability (Muscle Group XI) has been manifested by moderately severe impairment. 2. Prior to May 23, 2016, the Veteran’s unspecified anxiety disorder with major depressive disorder manifested with occupational and social impairment with reduced reliability and productivity. 3. From May 23, 2016, the Veteran’s unspecified anxiety disorder with major depressive disorder manifested with occupational and social impairment with deficiencies in most areas. 4. The Veteran’s service-connected non-Hodgkins lymphoma (from November 1, 2017 to March 13, 2019), unspecified anxiety disorder with major depressive disorder, left knee gunshot wound disability and scars, left hip arthritis, and hallux vagus do not preclude him from securing or following substantially gainful employment consistent with his education and industrial background.  CONCLUSIONS OF LAW 1. The criteria for a rating in of 20 percent, but no higher, for a left knee gunshot wound disability (Muscle Group XI) are met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4,55, 4.56, 4.71, 4.73, Diagnostic Code 5311. 2. Prior to May 23, 2016, the criteria for a 50 percent, but no higher, rating for an unspecified anxiety disorder with major depressive disorder are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.21, 4.126, 4.130, Part 4, Diagnostic Code (DC) 9413. 3. From May 23, 2016, the criteria for a rating in excess of 70 percent for an unspecified anxiety disorder with major depressive disorder are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.21, 4.126, 4.130, Part 4, Diagnostic Code (DC) 9413. 4. The criteria for entitlement to a TDIU are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19.  REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1967 to July 1972. This matter is on appeal from a January 2010 decision of a Department of Veterans Affairs (VA) Regional Office (RO). The case was previously before the Board in March 2015, July 2017, and October 2020 when it was remanded for further development. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3.      In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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 importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994).      Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1).      Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. For example, lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing observable symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).      In both initial and increased rating claims, the Board must consider staged ratings for the entire period on appeal. A staged rating is appropriate when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings under the applicable diagnostic code. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The potential for staged ratings accounts for the possible dynamic nature of a disability while the claim works its way through the adjudication process. Id. The Board has therefore considered the claims on appeal with the potential for a staged rating in mind.      The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided.     1. Left Knee Disability The Veteran contends that he is entitled to an increased rating for his service-connected left knee disability. The Veteran’s left knee disability is currently assigned a 10 percent evaluation under Diagnostic Code (DC) 5311 for a disability resulting from muscle injuries to Muscle Group XI. Disabilities resulting from muscle injuries to Muscle Group XI are classified as slight, moderate, moderately severe, or severe, and are rated as noncompensable (0 percent), 10 percent, 20 percent, and 30 percent, respectively. 38 C.F.R. § 4.73, Diagnostic Code 5311. The cardinal signs and symptoms of muscle disability are loss of power, leg weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. A slight disability of the muscles is characterized by a simple wound of muscle without debridement or infection. A slight disability of the muscle is reflected by history and complaint such as service department records of a superficial wound with brief treatment and return to duty. Healing of slight muscle injuries is followed by good functional results. A slight disability of muscles includes none of the cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c). Objective findings characteristic of slight muscle disability include minimal scarring, no evidence of fascial defect, atrophy, or impaired tonus, no impairment of function, and no metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). A moderate disability of the muscles results from a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. They manifest consistent complaints of one or more of the cardinal signs and symptoms of a muscle disability, particularly a lowered fatigue threshold. Some loss of deep fascia or muscle substance or impairment to muscle tonus and loss of power or lowered threshold of fatigue is expected. 38 C.F.R. § 4.56(d)(2). A moderately severe disability of muscles results from a through and through or deep penetrating wound with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. Records should indicate hospitalization for a prolonged period for treatment of the wound and consistent complaints of cardinal signs and symptoms of muscle disability with evidence of an inability to keep up with work requirements. A moderately severe disability also requires indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side; and tests of strength and endurance compared with the sound side demonstrating positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). A severe disability of the muscles results from through and through or deep penetrating wound with extensive debridement, prolonged infection, sloughing of soft parts, and intermuscular scarring and binding. It requires ragged, depressed and adherent scars; loss of deep fascia or muscle substance or soft flabby muscles in the wound area; and severe impairment on tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side. 38 C.F.R. § 4.56(d)(4). In this case, the Veteran was provided with a VA examination in November 2009. The examiner noted worsening since onset and becoming more frequently bothersome and severe over the 40 years since the initial injury. The Veteran reported that the pain was localized to the left knee with deep soreness, generally mild to non-existent at rest, but moderate and constant with ambulation. He reported fleeting jabs of pain lasting a few seconds at a time that are difficult to predict and sporadic but seemingly related the position of his left lower extremity. He denied weakness in the left leg but reported that it did seem to tire quicker than the right leg and at times it seems unstable when tired. The Veteran denies having ever fallen as a result of this condition. He reported flare-ups consisting of periods of several hours of more severe, deep aching pain (7-8/10) with a waxing and waning course during this period. He reported that it is not predictable and varies with overall activity level and type, and these episodes occur on average of about once a month, with precipitating activities including household chores such as mowing the lawn, digging in the garden, and chopping wood. He reported occasionally using medication and a hinged knee brace with activities that strain the joint. Other than mild swelling in the region of the joint, the Veteran denied any signs of inflammation. He denied any warmth, redness, or prolonged stiffness. He reported that he has “so far been determined not to allow his joint symptoms to interfere with performance of his usual daily activities, and the nature of his job as an office worker is generally not physically demanding.” The Veteran reported infrequent muscle symptoms including left calf and rare left thigh cramps which last a few minutes and generally do not limit usual daily or occupational activities. He reported that they may be precipitated by prolonged, intense activity of the lower extremities, such as squatting or swimming, and seem to be alleviated by massage of the affected muscle. He described some superficial numbness or decreased sensation of the distal portion of the left lateral thigh and knee which is noticeable if he compares to the right side but not bothersome and does not interfere significantly with usual daily or occupational activities. Upon examination, the examiner noted that the left knee was remarkable for mild crepitus with no objective evidence of pain with active motion against gravity or passive motion. There was no objective tenderness, instability, edema, or effusion. There was no atrophy and only a slight discrepancy in power (4+/5 versus 5/5) noted with both flexion and extension. No abnormalities were appreciated in the right knee. The examiner noted a deficit of subjective decrease in sensation to light touch and pinprick pain surrounding the surgical scar on the lateral aspect of the thigh. February 2012 records furnished by the Social Security Administration (SSA) reflect that the Veteran reported pain the left knee caused by all activities, to include bending, standing, walking, and temperature extremes. He reported daily pain that is not worse at certain times of the day. In August 2012, the Veteran was provided with an additional VA examination. The Veteran reported mechanical symptoms of clicking, grinding, catching, and giving way. He reported flare-ups which result in increased pain that are precipitated by activity such as performing yard work and last from 24 to 48 hours. Left knee flexion ended at 120 degrees with objective evidence of painful motion at 110 degrees. Left knee extension ended at 0 degrees with objective evidence of painful motion at 0 degrees. The Veteran was able to perform repetitive-use testing with 3 repetitions with left knee flexion at 120 degrees and extension at 0 degrees. The examiner noted excess fatigability, pain on movement, deformity, and disturbance of locomotion. The Veteran had tenderness or pain to palpation for joint line or soft tissue. Joint stability testing was normal. The examiner noted regular use of a brace for ambulation. The examiner noted that the left knee condition impairs ambulation and preclude performing work requiring prolonged standing, walking long distances, climbing, kneeling, or squatting. The examiner noted no muscle atrophy. The examiner stated that the Veteran “suffered a through and through injury to the left knee joint, the bullet appears to have entered his left knee just anterior to the medial femoral condyle behind the patella, and existed at the lateral knee joint line just anterior to the lateral collateral ligament.” He stated that the “bullet trajectory does not appear to have transected any muscle groups of the left lower leg or thigh and the damage appears to have been restricted to the structures of the left knee proper.” In May 2016, the Veteran was provided with an additional VA examination. The Veteran reported pain at the front of the knee and the knee intermittently giving out on him. He did not report flare-ups. Range of motion testing was normal. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional functional loss. The examiner noted that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use of a period of time. There was no reduction in muscle strength and no muscle atrophy. Joint stability testing was normal. The examiner noted that the Veteran did not use any assistive device as a normal mode of locomotion. He also noted that the condition does not impact the Veteran’s ability to perform any type of occupational tasks, such as standing, walking, lifting, or sitting. In a separate examination report, the examiner noted an injury to Muscle Group XI. The examiner noted that he found no evidence of neuropathy or radiculopathy during the examination. The Veteran had a normal gait with adequate strength and soft touch sensation was intact. The examiner noted that the Veteran drove in a car for 7 days and worked in his yard raking leaves, which indicated that he is capable of sedentary work and duties involving light activity. In May 2019, the Veteran was provided with an additional VA examination. The examiner noted muscle Group XI residuals with left knee pain and weakness with numbness due to left leg traumatic neuropathy, a medial left knee scar, and a lateral left knee scar. The examiner noted entrance and ragged scars. The examiner noted some loss of muscle substance. The examiner also noted consistent loss of power, weakness, lowered threshold of fatigue, fatigue pain, and impairment of coordination. Muscle strength testing was normal with no muscle atrophy. The examiner noted occasional use of a brace for locomotion. The examiner noted that the disability impacts his ability to work because the Veteran does not tolerate excessive, repetitive, or prolonged activity of the left lower extremity; tolerate prolonged inactivity; ascending or descending stairs; walking on uneven terrain; heavy lifting; nor, prolonged standing or walking. The examiner described the current level of severity as “moderate.” In a separate examination report, the examiner noted that the Veteran’s gait was not normal with a slow, deliberate, shuffling, and broad stance gait. Mild incomplete paralysis was noted in the external popliteal (common peroneal) nerve, anterior crural (femoral) nerve, and internal saphenous nerve. The examiner noted occasional use of a brace for locomotion. Upon review of the record, the Board finds that the symptoms discussed above more nearly approximate the criteria for a moderately severe muscle disability. Specifically, the Veteran provided credible and competent statements during the November 2009 VA examination that his left leg tires quicker than the right leg (reduced strength and endurance compared to the other side). Further, the May 2019 examiner noted some loss of muscle substance. Thus, the Board finds that the evidence is at least in equipoise that the Veteran’s disability meets the criteria for a moderately severe muscle disability as defined in 38 C.F.R. § 4.56(d)(3) throughout the appeal period. The Board has considered whether the Veteran’s disability meets the criteria for a rating in excess of 20 percent but finds that the functional impairment discussed above does not meet the criteria for severe impairment as defined in 38 C.F.R. § 4.56(d)(4). While the Veteran has provided competent and credible reports of impairment to endurance compared to the uninjured side, testing of strength, endurance, and coordinated movements compared to the uninjured side has not indicated severe impairment of function, as muscle strength testing was noted as normal upon examination. The record also contains no other indications of severe muscle disability including but not limited to X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; visible or measurable atrophy; adaptive contraction of an opposing group of muscles; atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; or, induration or atrophy of an entire muscle following simple piercing by a projectile. See 38 C.F.R. § 4.56(d)(4)(iii). The Board notes that while the May 2019 examiner described the left knee disability as an injury to Muscle Group XI and the August 2012 examiner noted a penetrating muscle injury, the August 2012 examiner made a finding that the bullet trajectory did not appear to have transected any muscle groups. As such, the Board has considered whether another Diagnostic Code would be appropriate in this case or provide for a higher rating. Specifically, the Board has considered the application of the rating criteria regarding musculoskeletal disabilities. See 38 C.F.R. §§ 4.3, 4.45, 4.7, 4.71a. However, the rating criteria for musculoskeletal disabilities of the knees assess the limitation of range under Diagnostic Codes 5260 and 5261 and, in this case, such criteria do not provide for a rating in excess of 20 percent as the Veteran’s range of motion does not reflect such a degree of limitation. Further, consideration of other Diagnostic Codes for rating a knee disability (5256, 5257, 5258, 5259, 5262, 5263) is inappropriate in this case as the Veteran’s left knee disability does not include the pathology required in the criteria for those Diagnostic Codes (ankylosis, recurrent subluxation or lateral instability, cartilage impairment with effusion, removal of cartilage, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. Thus, the Board finds that the rating criteria pertaining to evaluating musculoskeletal disabilities are not applicable in this case and would not provide for an increased rating. Accordingly, the Board finds that the Veteran’s disability picture more nearly approximates the criteria for moderately severe impairment. As such, a rating of 20 percent, but no higher, is warranted throughout the appeal period, and the claim is granted to that extent. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.55, 4.56, 4.71, 4.73, Diagnostic Code 5311. 2. Acquired Psychiatric Disorder The Veteran contends that he is entitled to an increased rating for his service-connected unspecified anxiety disorder with major depressive disorder. The acquired psychiatric disorder is currently assigned a 30 percent evaluation from October 8, 2009, 50 percent from August 3, 2012, and 70 percent from May 23, 2016. The regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Under the General Rating Formula, a 30 percent rating is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss.  A 50 percent rating is warranted for 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9434.  A 70 percent rating is warranted when there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id.  A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: 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 and place; memory loss for names of close relatives, own occupation, or own name. Id.  The list of symptoms in the General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, “a [V]eteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Furthermore, 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 solely based on social impairment. 38 C.F.R. § 4.126.  Prior to August 3, 2012 In this case, the Veteran was provided with a VA examination in November 2009 in which the examiner opined that the Veteran’s disability results in an occasional decrease in work efficiency with intermittent periods of an inability to perform occupational tasks due to mental disorder signs and symptoms with generally satisfactory functioning. The examiner noted that the Veteran prudently handled payments and personally handles money and pays bills. The examiner noted that the Veteran was currently employed full time since 1982 with an excellent work history. May 2011 private treatment records from Dr. J.P., a psychologist, stated that she believes that he “can see where you identify symptoms in both the 30 percent as well as the 50 percent ratings” and upon evaluation of the Veteran “during the past three months I have determined that he has a higher level of disability than 10 percent.” She noted recurrent and intrusive distressing recollections even while on medications. She stated that the Veteran at times falls to his knees when he hears a sudden loud sound. She noted intense psychological stress at exposure to internal or external cues that symbolize or resemble an aspect of the initial traumatic event. He stated that although his current medication helps, he continues to have intrusive thoughts of the trauma and diminished interest in participation in significant activities. He feels detached from others at times and presents with a restricted range of affect. He stated that his symptoms of memory loss and limited concentration caused gross impairment in thought processes and communication. He had nervousness, shakiness, a feeling of fearfulness, and difficulty socializing. She noted that although his periods of irritability and anger had decreased while on his current medication, he continued to have trouble controlling himself at times and that he was learning to cope but that some days are very difficult at work and home. He reported chronic insomnia with frequent awakenings at night which result in fatigue during the day. He reported that his thoughts are disorganized and that “messages get crossed in his mind at times.” Dr. J.P. stated that she believed that he “fits more appropriate … in the 40-50 percent range” and that he “has more than moderate to severe symptoms that decrease his work efficiency and ability to perform occupational tasks during times of stress.” She stated that he has “significant inability to function with routine behavior and his self-care is minimal due to his depressed mood, anxiety, chronic sleep impairment, memory loss, and suspiciousness.” October 2011 private treatment records note depression and constant worries and racing thoughts. He continued to have flashbacks, avoiding activities he used to enjoy, memory problems, and trouble concentrating. The Veteran reported being unable to sleep, go into work, stay focused on his work, or have the energy to perform his duties adequately. He reported suicidal thoughts with no plan or intent. May 2012 treatment records furnished by the Social Security Administration (SSA) note that the Veteran reported depression. He was casually dressed and groomed and was pleasant and cooperative. He had difficulty at times expressing himself. His psychomotor activity was slow, and he reported that he is not depressed unless he has to do things that bother him and does not have panic attacks anymore. He reported fleeting thoughts of suicide but no plans to act on it, no thoughts about it now, and no homicidal thoughts. He reported having not much energy and a loss of interest. He reported that he “hits the ground” when he hears a loud sound and has memories when he smells diesel fuel. He reported perceptual disturbances of sometimes hearing his name being called. His thought process was productive of thought and hesitant at times while rambling at other times. He reported that he has no delusions but “always has his eye out for people.” He had poor concentration and was oriented to time, place, and person. His judgment and insight were average, and his reliability was good. Clinician A.F., Ed.D., opined that the Veteran is not able to manage personal funds in a competent manner, and the Veteran reported that his wife manages the money. The Veteran reported limited social functioning and concentration, persistence, and pace as a little slow. June 2012 VA treatment records note that the Veteran was not suicidal or homicidal, not acutely psychotic or manic, and was not a danger to himself or others. Upon review of the record, the Board finds that the severity, duration, and frequency of the Veteran’s symptoms prior to August 3, 2012 more nearly approximated the criteria for occupational and social impairment with reduced reliability and productivity. The Board acknowledges the VA examination in which the examiner found no more than an occasional decrease in work efficiency with intermittent periods of an inability to perform occupational tasks due to mental disorder signs and symptoms with generally satisfactory functioning. However, the Board assigns greater probative weight to the May 2011 opinion by Dr. J.P., who provided a more thorough assessment of the Veteran’s symptoms and was able to observe his condition over three months. The November 2009 examination report does not reflect that the examiner elicited the full range of symptoms from the Veteran, as it does not address whether symptoms such as suicidal ideation were present. Thus, the Board finds that the symptoms described by Dr. J.P. best reflect the degree of functional impairment and disability picture during this period. Further, the Board acknowledges the credible reports of suicidal ideation discussed above, which is a symptom contemplated in the criteria for a higher rating. However, the record reflects that the frequency, severity, and duration of this symptomatology does not manifest as occupational and social impairment with deficiencies in most areas, as ideation was no more than fleeting with no current ideation or plans. The Board also acknowledges the August 2011 correspondence from the Veteran’s attorney in which he requested extraschedular consideration. Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the Veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant’s symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the Veteran’s disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. However, in this case, the Veteran’s disability picture is adequately contemplated in the schedular rating criteria, as there are no symptoms of the disability which are unaccounted for in the general rating formula for mental disorders. Thus, the facts of this case do not satisfy the first Thun element, and extraschedular consideration is not warranted. Accordingly, and having resolved all reasonable doubt in the Veteran’s favor, the Board concludes that the evidence of record most nearly approximates the criteria for a 50 percent, but no higher, rating for an acquired psychiatric disorder prior to August 3, 2012, and the claim is granted to that extent. 38 C.F.R. § 4.3. From August 3, 2012 The Veteran was provided with a VA examination in August 2012 in which the examiner opined that the Veteran’s disability results in occupational and social impairment with reduced reliability and productivity. She noted symptoms including excessive worry, sad mood most days, problems with sleep, little enjoyment in activities, and depression. The Veteran’s appearance was normal and appropriately groomed. His activity was normal with no psychomotor agitation. His attitude was cooperative, and speech was fluent and coherent with no pressure and no latency. His mood was anxious and depressed. His affect was appropriate. He denied hallucinations. His thought flow was spontaneous, linear, logical, and goal directed. He denied suicidal and homicidal ideation. He was alert and oriented to all spheres. His memory was intact, and attention was good. His intelligence was average, and judgment and insight were fair. He reported dreams about service and a panic attack within the past 8 months when he was feeling overwhelmed. Impulse control was good, and there were no recent episodes of violence. The examiner noted symptoms of depressed mood, anxiety, and chronic sleep impairment. The Veteran was capable of managing his own financial affairs. During this period, the evidence does not reflect more than occupational and social impairment with reduced reliability and productivity. The record does not reflect that the Veteran reported symptoms contemplated in the criteria for an increased rating. As discussed by the August 2012 examiner, the Veteran’s symptoms during this period resulted in occupational and social impairment with reduced reliability and productivity. The record contains no other evidence during this period which otherwise indicates functional impairment which resulted in deficiencies in most areas. Accordingly, the Veteran’s symptoms most nearly approximated the criteria for a 50 percent, but no higher, rating for an acquired psychiatric disorder from August 3, 2012. 38 C.F.R. § 4.3. From May 23, 2016 In May 2016, the Veteran was provided with an additional VA examination in which the examiner opined that the Veteran’s disability results in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. The Veteran was casually dressed and adequately groomed with a pleasant, polite, and cooperative attitude. His speech was fluent, soft, and coherent. His mood was depressed. His affect was appropriate and mood congruent. He reported no hallucinations, and his thought flow was logical and goal directed with no delusions. He reported no suicidal or homicidal ideation. He was oriented to all spheres with good attention. The examiner noted symptoms of depressed mood, anxiety, near-continuous panic or depression, chronic sleep impairment, mild memory loss such as forgetting names, directions, or recent events, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. She also noted impaired concentration, low energy, anhedonia, isolative, and unwanted memories. The Veteran was capable of managing his own financial affairs. The examiner noted four separate, primary capacities that impact employment: understanding and memory, fair; sustained concentration and persistence, fair to poor; social interaction, fair; and, adaptation, fair. She noted that the Veteran’s depression has increased since 2012 but his anxiety has remained the same. His short-term memory and concentration had diminished since retirement and he was less interested in socialization or activities he used to enjoy. He reported feeling little enjoyment or satisfaction. He reported getting along with others but preferred not to socialize much outside of his family. His motivation and energy levels were “very low.” The Veteran was provided with an additional VA examination in May 2019 in which the examiner noted occupational and social impairment with reduced reliability and productivity. She noted that the Veteran reported worsening memory and difficulties planning his driving routes. He reported nightmares related to service and a feeling of anxiety and insecurity. He reported struggling with social isolation and stated that he has “just one friend, I do not go anywhere except for a grocery store, I do not feel safe in my surroundings.” He reported being bothered by anger issues. The examiner noted symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, difficulty in understanding complex command, difficulty in establishing and maintaining effect work and social relationships, and difficulty in adapting to stressful circumstances. His affect was somewhat constricted with anxiety and sadness, and his memory and orientation were somewhat impaired. The examiner noted that the Veteran was somewhat confused as to the building layout. He had no audiovisual hallucinations and no suicidal or homicidal ideation. He reported nightmares, intrusive recollections, and hyperarousal. He reported “a breakdown at work and felt very anxious and paranoid” around 2005. Upon review of the record, the Boards finds that the Veteran’s disability picture during this period did not more nearly reflect total occupational and social impairment. During this period, the Veteran did not exhibit symptoms contemplated in the criteria for an increased rating. He presented with a coherent and logical thought process and was able to clearly communicate with the examiners. The Board acknowledges that the Veteran appeared confused as to the building layout during the May 2019 examination. However, this does not reflect general disorientation to time or place, as the Veteran merely had difficulty navigating in through the examination building. The record does not otherwise reflect such confusion during the ordinary conditions of daily life. Accordingly, the Veteran’s symptoms most nearly approximated the criteria for a 70 percent, but no higher, rating for an acquired psychiatric disorder from May 23, 2016. 38 C.F.R. § 4.3. TDIU The Veteran contends that he is unable to secure or follow substantially gainful employment due to his service-connected disabilities. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the Veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a).    The established policy of VA reflects that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Factors such as employment history and educational and vocational attainments are to be considered. Id. For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The word “substantially” suggests an intent to impart flexibility into a determination of overall employability, as opposed to requiring the appellant to prove that he is 100 percent unemployable. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001).    The Court has held that the term “unable to secure and follow a substantially gainful occupation” in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual Veteran’s ability to “follow and secure” employment. For the second component, attention must be given to: (1) the Veteran’s history, education, skill and training, (2) the Veteran’s physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (3) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019).    Moreover, age is not a factor to be considered in evaluating the Veteran’s unemployability. 38 C.F.R. § 4.19. If the Board determines that the Veteran’s unemployability was a result of his age and non-service-connected disabilities, the Board is still required to decide, without regard to the non-service-connected disabilities or age, whether the Veteran’s service-connected disabilities are sufficiently incapacitating as to render him unemployable. Pratt v. Derwinski, 3 Vet. App. 269, 272 (1992).    VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).    In this case, the Veteran has been assigned the following non-total rated service-connected disabilities: non-Hodgkins lymphoma rated as noncompensable (from November 1, 2017 to January 6, 2010); unspecified anxiety disorder with major depressive disorder rated at 50 percent from October 8, 2009 and 70 percent from May 23, 2016; left knee gunshot wound residuals at 20 percent; left knee scars rated at 10 percent; left hip arthritis at 10 percent; and, hallux valgus rated as noncompensable. The Veteran therefore meets the percentage requirements for a schedular TDIU. Thus, the remaining question is whether the Veteran’s non-total rated service-connected disabilities alone render him incapable of participating in a substantially gainful employment. Initially, the Board notes that the Veteran explained during an August 2012 VA examination that he was employed until November 1, 2011 when he learned that his lymphoma had returned. He reported that he needed to resume chemotherapy and needed to use sick leave. The record reflects that the Veteran has been assigned a total rating (100 percent) for the non-Hodgkin’s lymphoma from October 2009 to November 2017 and from March 2019. Thus, the Veteran has already been awarded the maximum allowable rating for this period for his lymphoma which resulted in his unemployability. The primary inquiry in a TDIU claim is whether the Veteran’s non-total rated service-connected disabilities alone are sufficiently incapacitating as to render him unemployable. Therefore, the analysis undertaken below will not consider the symptoms of the Veteran’s lymphoma for the period in which he was assigned a total rating for this disability. Instead, with regard to the Veteran’s lymphoma, the analysis will only reflect consideration of the functional impairment of the lymphoma during the period of remission from November 2018 to March 2019. In this case, a November 2009 VA examination reflects that the Veteran was employed as a Geographic Information Systems (GIS) Analysist full time since 1982 with no time lost from work during the last 12-month period. He reported an “excellent work history” with 10 months of sick leave. The examiner noted impairment in the Veteran’s ability to perform physical activities like digging and mowing the lawn due to the left knee disability. In a November 2009 VA examination for the acquired psychiatric disorder, the examiner noted that anxiety affects him at work and causes him to make mistakes at work and sometimes causes difficulty initiating and completing tasks. In August 2011, the Veteran was provided with VA examinations for his service-connected psychiatric disorder, scars, hip condition, lymphoma, foot condition, and knee disability. The examiner noted that the Veteran ambulated with a moderate antalgia and disordered gait. March 2012 records furnished by the Social Security Administration (SSA) reflect that the Veteran reported difficulty with lifting, squatting, bending, standing, walking, kneeling, and stair climbing. He reported that he can walk up to a mile before needing to stop and rest and resting for 10 to 15 minutes before he can resume walking. He reported that his attention is good and he finishes what he starts, such as chores. He reported that he can follow written and spoken instructions very well. He reported that he does not handle stress well at all. In August 2012, the Veteran was provided with VA examinations for the psychiatric disorder, left knee disability, and foot disability. The examiner also noted a limp favoring the left leg. The examiner noted foot pain which limits ambulation and prolonged standing. The examiner noted that the left knee condition impairs ambulation and precludes performing work requiring prolonged standing, walking long distances, climbing, kneeling, or squatting. Regarding the psychiatric disorder, the examiner noted that the Veteran worked with coworkers for many years and had been the “go to person” at work until he had to leave due to his lymphoma. The examiner noted one panic attack in the past 8 months when he was feeling overwhelmed. She noted that the Veteran’s anxiety and depression cause moderately severe impairment in social and occupational functioning. In May 2016, the Veteran was provided with a VA examination for the psychiatric disorder. The examiner noted occupational and social impairment with deficiencies in most areas. The examiner noted workplace impairment due to anxiety and depressive disorder with fair understanding and memory, fair to poor sustained concentration and persistence, fair social interaction, and fair adaptation. She also noted diminishment in short term memory and concentration since retirement. The Veteran was also provided with VA examinations for the knee disability in May 2016. The examiner noted that the Veteran “drove in a car for 7 days and then worked in his yard raking leaves.” The examiner noted that this indicated that he is capable of sedentary work and duties involving light activity. In a March 2019 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, the Veteran reported 16 weeks of time lost due to illness. He stated that his PTSD, left knee disability, and lymphoma prevent him from securing or following substantially gainful employment. In May 2019, the Veteran was provided with VA examinations for the left knee disability and psychiatric disorder. The examiner noted that the Veteran does not tolerate excessive, repetitive, or prolonged activity of the left lower extremity nor prolonged inactivity. The Veteran also did not tolerate ascending or descending stairs, walking on uneven terrain, heavy lifting, nor prolonged standing or walking. Regarding the Veteran’s psychiatric disorder, the examiner noted difficulty establishing and maintaining effect work and social relationships and difficulty in adapting to stressful circumstances, including work or in a worklike setting. Regarding the Veteran’s specific education, training, skill, and experience, he has completed four years of high school and indicated that he has completed some college courses. The record also reflects that the Veteran can follow instructions and complete tasks necessary for administrative type work, as shown in his ability to maintain employment as a GIS analyst prior to leaving his employment due to his lymphoma. The Board acknowledges the Veteran’s reports of impairment regarding panic attacks and impaired ability to concentrate. However, the record does not reflect that these symptoms manifest with such a severity that they preclude all forms of gainful employment, as the Veteran has shown that he is able to present himself professionally and communicate clearly and logically. Regarding the Veteran’s physical ability (both non-exertional and exertional), the Board acknowledges that the Veteran’s service-connected disabilities cause functional impairment, to include an inability to perform extended or prolonged physical activities such as walking. However, notwithstanding the functional impairment discussed above, the record reflects that the Veteran’s physical ability permits sedentary and semi-sedentary employment and employment involving very light physical work, as explained in the examiner who noted that the Veteran is able to drive and perform yardwork. This limitation in physical ability renders the Veteran unable to perform tasks more strenuous than extended walking or lifting but would not preclude occupations which physically require no more than light walking, sitting, standing, grasping, and reaching, such as a job involving administrative tasks for which the Veteran has the skills, experience, and education. While VA law does not define “sedentary,” the Board can give the term meaning and relevance on a case-by-case basis addressing the medical and lay evidence in light of the veteran’s education, training, and work history. Specifically, where a veteran’s ability to perform sedentary work is a basis for the Board’s decision, the meaning of sedentary work must be determined from the particulars of the medical opinion in which it is used. That is, the Board must explain this meaning to the extent that it is not apparent from the Board’s overall discussion of the opinion as well as how the concept of sedentary work factors into the veteran’s overall disability picture and vocational history, and the Veteran’s ability to secure or follow a substantially gainful occupation. Withers v. Wilkie, 30 Vet. App. 139, 147 (2018). As such, using the Merriam Webster dictionary definition of “sedentary” (not migratory; doing or requiring much sitting; not physically active) and in light of the evidence discussed above, the Board defines sedentary employment as occupations that involve much sitting, and do not call for much physical activity. Although sedentary work is defined to include much sitting, a certain amount of walking and standing is often necessary in carrying out job duties in sedentary employment. The Veteran’s limitations discussed above reflect that he can perform a limited degree of physical tasks such as walking and grasping objects, such as a telephone or pen. His education, training, skill, and experience reflect an ability to communicate clearly, follow instructions, and complete tasks which are necessary for sedentary type employment or employment involving very light physical work, such as administrative type employment. Accordingly, the Board finds that the Veteran’s non-total rated service-connected disabilities do not preclude him from securing or following substantially gainful employment consistent with his education and industrial background. In reaching this determination, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim that doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).    M. Mills Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. White, 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.