Citation Nr: 21024821 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 14-40 913 DATE: April 26, 2021 ORDER Service connection for chronic fatigue syndrome (CFS), or a disability manifested by chronic fatigue, is denied. An initial rating in excess of 50 percent prior to October 16, 2018, and in excess of 70 percent thereafter for posttraumatic stress disorder (PTSD) is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to October 16, 2018, is denied. FINDINGS OF FACT 1. At no time during the pendency of the claim does the Veteran have a current disability related to a diagnosis of CFS and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of a claim, and her symptom of fatigue is already compensated in the assigned rating for her service-connected PTSD. 2. For the appeal period prior to October 16, 2018, the Veteran’s PTSD was manifested by symptomatology resulting in occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 3. As of October 16, 2018, the Veteran’s PTSD is manifested by symptomatology resulting in occupational and social impairment with deficiencies in most areas, without more severe manifestations that more nearly approximate total occupational and social impairment 4. For the appeal period prior to October 16, 2018, the Veteran’s service-connected disabilities did not render her unable to secure or follow a substantially gainful occupational consistent with her education and work history. CONCLUSIONS OF LAW 1. The criteria for service connection for CFS, or a disability manifested by chronic fatigue, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. 2. The criteria for an initial rating in excess of 50 percent prior to October 16, 2018, and in excess of 70 percent thereafter for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 3. Prior to October 16, 2018, the criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Marine Corps from January 1983 to October 1984 and in the Army from January 1992 to April 1992, with additional service in the Army National Guard from September 1988 to June 1989. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before a Decision Review Officer (DRO) in March 2015, and at a Board hearing before the undersigned Veterans Law Judge in November 2015. Transcripts of the hearings are associated with the record. In May 2017, the Board remanded the instant claims, as well as claims for service connection for hypertension, chronic headaches, temporomandibular joint (TMJ) dysfunction, and cough-variant asthma for additional development. While on remand, in a September 2018 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for hypertension and muscle contraction/tension headaches. As such are full grants of the benefits sought on appeal with respect to these issues, these matters are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). Additionally, in a May 2019 rating decision, the AOJ increased the rating of the Veteran’s PTSD to 70 percent and awarded a TDIU, effective October 16, 2018. In November 2019, the Board granted service connection for cough-variant asthma, denied an increased rating for the Veteran’s PTSD, and remanded the claims for service connection for CFS and entitlement to a TDIU prior to October 16, 2018, for additional development. The Veteran subsequently appealed the Board’s denial of an increased rating for her PTSD to the U.S. Court of Appeals for Veterans Claims (Court). In October 2020, the Court granted the Veteran’s and the Secretary of VA’s (the parties’) Joint Motion for Partial Remand (JMPR), which vacated and remanded the Board’s November 2019 decision as to such issue. Additionally, in a November 2020 rating decision, the AOJ granted service connection for TMJ dysfunction. As such is a full grant of the benefit sought on appeal with respect to such issue, it is no longer before the Board. See Grantham, supra. All remaining claims now return to the Board for further appellate review. The Board observes that, subsequent to the issuance of the most recent supplemental statement of the case that addressed the Veteran’s claim for an increased rating for her PTSD in April 2019, the AOJ obtained additional evidence, to include updated VA treatment records. However, as such newly received evidence is irrelevant to such issue, or contains findings that are duplicative to those previously considered by the AOJ, the Board finds no prejudice to the Veteran in proceeding with a decision on such claim at the present time. 38 C.F.R. § 20.1305(c). 1. Entitlement to service connection for CFS, or a disability manifested by chronic fatigue, claimed as due to exposure to contaminated water at Camp Lejeune and/or as secondary to service-connected PTSD. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C. § 1110; 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Additionally, VA has acknowledged that persons residing or working at the U.S. Marine Corps Base Camp Lejeune from August 1, 1953, through December 31, 1987, were potentially exposed to drinking contaminated water with volatile organic compounds. See Veterans Benefits Administration Fast Letter 11-03 (January 11, 2011). In this regard, VA has established a presumption of service connection for certain diseases for veterans, former reservists, and former National Guard members who were exposed to contaminants in the water supply while serving at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953, to December 31, 1987. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Specifically, effective March 14, 2017, 38 C.F.R. § 3.309 (f) was amended to provide a presumption of service connection for kidney cancer, liver cancer, Non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer, which have become manifest to a degree of 10 percent or more at any time after service if the veteran was stationed at Camp Lejeune between August 1, 1953, and December 31, 1987. Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term “disability” as used in 38 U.S.C. § 1110 ”refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and held that “pain alone can serve as a functional impairment and therefore qualify as a disability”). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In the May 2017 remand, the Board noted that the Veteran alleged that her claimed CFS was related to neurobehavioral effects caused by her exposure to contaminated water at Camp Lejeune or, in the alternative, was caused or aggravated by her PTSD as such symptomatology interfered with her sleep. In this regard, the Board observed that the Veteran’s treatment records reflected complaints of fatigue. Accordingly, the Board found that a remand was necessary in order to afford the Veteran a VA examination so as to determine the current nature and etiology of her claimed CFS, to include whether such was related to her acknowledged in-service exposure to contaminated water at Camp Lejeune and/or caused or aggravated by her service-connected PTSD. Thereafter, an April 2018 VA medical opinion was obtained regarding the relationship between the Veteran’s claimed CFS and her exposure to contaminated water at Camp Lejeune (wherein the examiner simply determined that a current diagnosis of CFS was not confirmed), the Veteran was not afforded a VA examination pursuant to the May 2017 Board remand instructions. Therefore, the Board remanded the claim in November 2019 in order to afford the Veteran a VA examination that fully addressed the nature and etiology of her claimed CFS. On remand, such examination was conducted via telephonic interview and opinions were issued in July 2020 and August 2020 that addressed the Veteran’s claimed CFS. In this regard, the July 2020 examiner noted that August 2013 and December 2014 records completed by a licensed professional mental health counselor noted chronic fatigue syndrome as an Axis II diagnosis, and stated that, if the Veteran was presumed to have such a diagnosis, it was less likely than not that such was related to her acknowledged exposure to contaminated water at Camp Lejeune due to a lack of scientific literature documenting a link between such. In this regard, he noted the Veteran’s assertion that her claimed fatigue is related to neurobehavioral effects due to exposure to contaminated water at Camp Lejeune, but found that no scientific basis exists for any association between such exposure and CFS or isolated fatigue. The examiner also cited scientific literature explaining the lack of consensus regarding which scientific criteria to utilize in diagnosing CFS. In light of the fact that the diagnosis of CFS was made as an Axis II diagnosis by a licensed professional mental health counselor, the examiner questioned whether the Veteran did indeed have a diagnosis of CFS made by an appropriate clinician utilizing a proper assessment. In this regard, he referenced medical records from March 2014 and April 2019 stating that the Veteran had no diagnosis of CFS. Finally, the examiner attributed any symptoms of chronic fatigue to the Veteran’s PTSD, which was noted to be manifested by sleep disturbances, nightmares, and depressed feelings, as it is well-established that fatigue and exhaustion often accompany symptoms of PTSD. In August 2020, a different VA examiner reviewed the record, interviewed the Veteran, and conducted an examination, and found that her claimed CFS was less likely than not proximately due to, the result of, or aggravated by her PTSD as she did not have a confirmed diagnosis of CFS as reflected in the record or on the current examination. In this regard, she found that there was no objective evidence of evaluation by a neurologist or rheumatologist diagnosing or treating CFS. The examiner further noted that the Veteran did not report findings, signs, or symptoms attributable to CFS, and the objective clinical evidence did not support such a diagnosis. Further, the examiner found that her reported fatigue did not impact her ability to work. Rather, the Veteran had specifically denied having been diagnosed with CFS at the examination, and stated that she intended for her service connection claim to be for “chronic fatigue.” Subsequent to this examination, the Veteran submitted a statement in support of her claim and clarified that she does not have CFS, for which she has never received a diagnosis. See February 12, 2021 Statement in Support of Claim. However, she argued that her “symptom” of chronic fatigue should be separately service-connected. In this regard, the Veteran reiterated that her claim for service connection was for the symptom of chronic fatigue as opposed to the clinical diagnosis of CFS. Based on the foregoing, the Board finds that at no time during the pendency of the claim does the Veteran have a current disability related to a diagnosis of CFS and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of a claim. See McClain, supra; Romanowsky, supra. In this regard, the Board is cognizant that a licensed professional mental health counselor provided such a diagnosis; however, as noted by the July 2020 and August 2020 VA examiners, she lacked the clinical expertise to render such diagnosis and it was not otherwise supported by objective examinations. Moreover, while the Veteran’s symptom of fatigue has been related to her service-connected PTSD, the Board finds that such is already compensated in the assigned rating for such service-connected disability. In this regard, chronic sleep impairment and residual symptoms thereof, such as fatigue, are specifically contemplated in the rating criteria for the Veteran's service-connected disability of PTSD (DC 9411) and, thus, she is already compensated for such symptomatology. Therefore, to assign a separate rating for fatigue as a manifestation of such service-connected disability is tantamount to pyramiding. 38 C.F.R. §§ 4.14, 4.130; Esteban v. Brown, 6 Vet. App. 259, 261–62 (1994). Ultimately, while the Veteran is competent to describe her symptom of fatigue, as a layperson she is not competent to attribute such symptomatology to a specific disability, to include CFS, as such pertains to a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Specifically, such a diagnosis involves specialized testing and knowledge of the nervous system. As such, the Veteran's opinion as to the presence of a disability manifested by fatigue separate and distinct from an already service-connected disability is entitled to no probative weight. Therefore, based on the foregoing, the Board finds that at no time during the pendency of the claim does the Veteran have a current disability related to a diagnosis of CFS and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of a claim, and her symptom of fatigue is already compensated in the assigned rating for her service-connected PTSD. Thus, service connection for CFS, or a disability manifested by chronic fatigue, is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for CFS or a disability manifested by chronic fatigue. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 2. An initial rating in excess of 50 percent prior to October 16, 2018, and in excess of 70 percent thereafter for PTSD. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155, 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. When there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran’s PTSD is evaluated as 50 percent disabling as of May 15, 2013, the date of service connection, and 70 percent disabling as of October 16, 2018, pursuant to the criteria of DC 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130. Under DC 9411, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairments of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted when there is 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas”— i.e., “the regulation... requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.’“ Vazquez-Claudio, 713 F.3d at 117–18; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation based on all the 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.” 38 C.F.R. § 4.126 (a). In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the General Rating Formula “indicates that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas.” However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran’s service-connected psychiatric disability, and their resulting social and occupational impairment. The Board notes that the revised DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (August 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, 29 Vet. App. 221 (2018). The pertinent evidence of record related to the Veteran’s initial rating claim consists of VA examination reports dated in December 2013, April 2015, and October 2018; her testimony provided at her November 2015 Board hearing; her private and VA treatment records dated throughout the appeal period; and Social Security Administration (SSA) records. As an initial matter, the Board notes that the parties to the JMPR found that the November 2019 Board decision failed to address relevant evidence of record indicating that the Veteran may have neglected her personal appearance and hygiene at points during the period on appeal. Furthermore, they agreed that the Board failed to adequately address the lay statements of record indicating that the Veteran’s occupational functioning may have been more than moderately impacted by her PTSD. Such evidence will be discussed, infra. However, even with full consideration of the evidence enumerated in the JMPR, the Board finds that an initial rating in excess of 50 percent prior to October 16, 2018, and a rating in excess of 70 percent thereafter for PTSD is not warranted. Turning to the evidence of record, private treatment records dated from May 2013 to August 2015 reflect ongoing mental health treatment. Specifically, such show a report that the Veteran’s anxiety could interfere with her ability to focus and process information, and she experienced mood instability. Additionally, she endorsed nightmares and flashbacks, racing thoughts, and poor focus and concentration. She indicated that she experienced loss of energy, being withdrawn, being easily irritable, isolation, angry outbursts, poor appetite, panic attacks, hopelessness, anxiety, inappropriate guilt, depression, insecurity, fatigue, difficulty controlling worry, and insomnia. However, she denied suicidal ideation and hallucinations. The Veteran also reported that she could not stay in a relationship. It was noted that during mental health examinations, the Veteran was alert and well-groomed; had no gross abnormalities of motor skills; her recent memory appeared impaired; her thought content was within normal limits; her judgment was fair; and her speech was goal-oriented. The Board acknowledges that, in a November 2013 private PTSD Disability Benefits Questionnaire (DBQ), Dr. D.A. noted diagnoses of generalized anxiety disorder (GAD), major depressive affective disorder, attention-deficit/hyperactivity disorder (ADHD), and PTSD, which were found to result in total occupational and social impairment, which is commensurate with a 100 percent rating under the General Rating Formula. Here, he found that it was possible to differentiate what symptom was attributable to each of the Veteran’s diagnoses. Specifically, Dr. D.A. noted the Veteran’s panic, fear, and anxiety were due to her GAD; her flattened affect, hopelessness, and helplessness were due to her major depressive affective disorder; her flashbacks and extreme fear of people, places, and things were due to her PTSD; and her lack of focus, hyperactivity, impulsivity, and weight loss were due to her ADHD. He further indicated that the Veteran’s psychiatric disabilities result in additional symptoms of depressed mood; suspiciousness; panic attacks more than once a week; chronic sleep impairment; impairment of short-and long-term memory; impaired judgment; disturbances of motivation and mood; inability to establish and maintain effective relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; suicidal ideation; obsessive rituals; spatial disorientation; grossly inappropriate behavior; neglect of personal appearance and hygiene; and disorientation to time and place. VA and SSA treatment records dated from November 2013 to August 2018 similarly reflect ongoing mental health treatment. Specifically, mental status examinations reveal that the Veteran reported experiencing night sweats, nightmares, intrusive thoughts, anxiety, hypervigilance, isolation, a restricted range of emotions, hypersomnia, loss of interest, hopelessness, and depressed mood. She further reported an avoidance of men, poor concentration, and difficulty maintaining focus. It was noted that the Veteran’s thought processes/content, insight/judgment, and speech were within normal limits. Though her immediate memory appeared to be impaired, she had good impulse control. It was further noted that the Veteran was alert and oriented, and well-groomed. She consistently denied suicidal and homicidal ideations, hallucinations, delusions, and paranoia. The Board further acknowledges that a June 2013 SSA record indicates a determination that the Veteran was disabled from June 30, 2013, to November 30, 2014 due to her affective/mood and anxiety disorders. This finding is echoed in the Veteran’s lay statements of record regarding her occupational functioning during this timeframe, as was discussed in the JMPR. See August 6, 2015 Mental Health Outpatient Note; June 2016 SSA Hearing Transcript; October 2018 VA Examination Report; October 2018 Application for Increased Compensation Based on Unemployability; October 2018, November 2018, and May 2019 Statements. However, the SSA findings factored in other disabilities affecting the Veteran’s functional abilities in the workplace, to include her nonservice-connected attention deficit disorder. In this regard, the SSA determination decision recognized that the Veteran’s difficulty with attention caused her anxiety. Also, the SSA finding and the Veteran’s lay statements are inconsistent with the contemporaneous objective evidence of record regarding the severity of her PTSD symptomatology during this time period. In this regard, such evidence demonstrates that the Veteran did experience occupational and social impairment with reduced reliability and productivity due to symptoms of PTSD, but that such symptomatology did not result in occupational and social impairment in most areas, or total occupational and social impairment. In this regard, the Veteran was afforded a VA examination in December 2013. On examination, the examiner noted a diagnosis of PTSD that most likely originated in multiple childhood traumas, which was found to result in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by medication, which is commensurate with a 10 percent rating under the General Rating Formula. In this regard, the examiner found that the symptoms attributable to the Veteran’s PTSD included depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, and disturbances of motivation and mood. The examiner also noted that the Veteran smiled and laughed frequently when she was feeling anxious; otherwise, her behavior was within normal limits. Thereafter, the Veteran was afforded an additional VA examination in April 2015. On examination, the examiner noted diagnoses of PTSD and ADHD, which were found to result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, which is commensurate with a 30 percent rating under the General Rating Formula. Here, she found that it was possible to differentiate what symptom was attributable to each of the Veteran’s diagnoses. Specifically, the examiner noted the Veteran’s difficulties with distractions and sustained attention were due to her ADHD, and her avoidant behavior, hypervigilance, sleep disturbance, and nightmares were due to her PTSD. She further indicated that the Veteran’s psychiatric disability results in additional symptoms of depressed mood; anxiety; panic attacks more than once a week; mild memory loss; and difficulty in adapting to stressful circumstances, including work or a worklike setting. Furthermore, the examiner noted that the Veteran was neatly groomed and cooperative, she smiled often, and her speech tone and rate were within normal limits, her thought process was logical and goal-oriented, there were no indications of hallucinations or delusions, and she denied any active suicidal/homicidal thoughts or plans. At the Veteran’s November 2015 Board hearing, she reported the following mental health symptoms: difficulty sleeping; hypervigilance; concentration and memory problems; daily panic attacks; depression; fatigue; and headaches. As noted by the parties in the JMPR, the Veteran’s friend K.R. submitted a statement in September 2015 in which she described one instance in October 2012, which is prior to the date the Veteran’s PTSD was service-connected, when the Veteran experienced an increase in psychiatric symptomatology and did not bathe for several days, and a July 2017 VA treatment record that reflects the Veteran’s report that she had not changed clothes, showered, or brushed her teeth for five days prior to the appointment. In this regard, K.R. further stated that, during long periods of isolation, without support from and contact with her good friend, the Veteran had the tendency to neglecting her personal hygiene while at home by herself. In October 2018, the Veteran was afforded an additional VA examination. On examination, the examiner noted diagnoses of PTSD and ADHD, which was found to result in occupational and social impairment with deficiencies in most areas, which is commensurate with a 70 percent rating under the General Rating Formula. Here, the examiner found that it was not possible to differentiate what symptom was attributable to each of the Veteran’s diagnoses. Specifically, the examiner explained that the Veteran’s mental health disorders had developed in association with one another. The examiner further indicated that the Veteran’s psychiatric disability results in symptoms of depressed mood, anxiety, suspiciousness; panic attacks more than once a week; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss; impairment of short-and long-term memory; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and suicidal ideation. Furthermore, she noted that the Veteran’s hygiene and grooming were appropriate; she was alert and oriented to time, place, and person; her thought processes were logical and goal-oriented; her speech was unremarkable; her conversation gave no indication as to any psychosis or mania; her judgment appeared intact; she did not have any indication of impaired judgment; she was able to independently complete activities of daily living; and she reported passive suicidal and homicidal ideation with no intent or plan. Moreover, the examiner determined that, if the Veteran were to pursue gainful employment, it would be anticipated that she would display significant difficulty maintaining adequate job attendance, completing tasks that required sustained attention and/or concentration, interacting with others appropriately, following directions correctly, and maintaining adequate performance standards. Here, the examiner noted that such impairments would most likely manifest in both physical and sedentary work environments. VA treatment records dated in December 2018 to May 2019 reveal that the Veteran was alert and oriented, and had an appropriate affect. She also experienced mood lability; difficulty with social interaction, anxiety attacks, avoidance of public spaces, poor concentration, thoughts of death, and difficulty performing activities of daily living. Additionally, a February 2019 private treatment record reveals that the Veteran was withdrawn, isolated, and had significant problems getting along with co-workers. Such record further reveals that the Veteran had problems with concentrating, low stress tolerance, depressed energy, neglect of self-care, problems with relationships, and poor sleep. Subsequent VA treatment records reveal an improvement in the Veteran’s PTSD symptomatology and social functioning as she reported that she was doing well, with improved mood, motivation, and sleep quality, and less anxiety and hypervigilance. Further, she reported that she had traveled out of town with her daughter, was auditing classes, and planned to return to school. Based on the foregoing, the Board finds that, an initial rating in excess of 50 percent for PTSD, for the appeal period prior to October 16, 2018, is not warranted. In this regard, the Veteran has never reported symptoms commensurate with a 100 percent rating, nor do treatment records or examinations reflect any such symptoms throughout such appeal period. Furthermore, while she has reported some symptoms as contemplated by a 70 percent rating, such are not shown to be of a nature, frequency, duration, and severity as to result in social and occupational impairment with deficiencies in most areas. Here, while the Veteran had been found to have difficulty in adapting to stressful circumstances (including work or a work like setting), she had worked as a GED teacher and as a Veteran’s Service Representative, and completed a college course. See December 2013 and April 2015 VA Examination Reports. The record further reflects that the Veteran participated in a vocational rehabilitation program and held additional technical/teaching positions until August 2018. See VA Form 21-8940; October 2018 VA Examination Report. Additionally, while the Veteran had reported difficulty with establishing and maintaining effective social relationships, she had, in fact, maintained some close relationships for long periods of time, including those with her two adult children and a friend whom she had known for 24 years as consistently reported at all VA examinations. Thus, while she has some difficulty establishing and maintaining relationships, she had not been shown to be unable to do so. Furthermore, the Veteran had consistently endorsed irritability and anger outbursts; however, despite the frequency and report severity of such anger, she had shown the ability to control such symptom to prevent periods of violence. Thus, her impulse control is intact. Additionally, as noted previously, the Board acknowledges K.R.’s September 2015 report that the Veteran had periods where she had a tendency to neglecting her personal hygiene while at home by herself and a July 2017 VA treatment record that reflects the Veteran’s report that she had not changed clothes, showered, or brushed her teeth for five days prior to the appointment. However, the Board finds that the occasional failure to engage in regular grooming while at home alone is not shown to be of a nature, frequency, severity, or duration to result in a greater degree of occupational and social impairment than as contemplated by the currently assigned 50 percent rating. In this regard, the statement from K.R. reflects that the Veteran was able to maintain a very close, supportive friendship during this time and, as will be further discussed herein, the Veteran was able to pursue educational and professional opportunities. Furthermore, in a subsequent statement in May 2016, K.R. described the Veteran’s isolating tendencies and propensity to eat junk food, but did not mention any ongoing concern regarding the Veteran’s personal hygiene. Furthermore, all other VA and private medical reports, as well as SSA records, from this time period indicate that the Veteran’s hygiene and grooming were appropriate. Moreover, the remainder of the Veteran’s psychiatric symptoms noted throughout this appeal period are explicitly contemplated by the rating criteria for a 10, 30, or 50 percent rating under the General Rating Formula. Furthermore, regardless of the classification of the Veteran’s symptoms under the General Rating Formula, the Board finds that the totality of such, to include consideration of their nature, frequency, duration, and severity, result in, at most, occupational and social impairment with reduced reliability and productivity prior to October 16, 2018. In this regard, as noted previously, while the Veteran reported that she could not stay in a relationship and avoided men, she had maintained close relationships with her children, K.R., and a long-term friend, who is male. The record further shows that, as will be discussed at length in the next section, the Veteran has been able to maintain employment in multiple teaching/technical analysis positions throughout the appeal period. In this regard, as noted by the parties to the JMPR, the Veteran has alleged that she was unable to maintain employment because she quit or was terminated from each job due to her PTSD; however, such report is not supported by the remainder of the evidence of record. Specifically, such demonstrates that she was gainfully employed throughout most of the appeal period, obtained new positions (to include as an adjunct professor), maintained her own business as CEO, and engaged volunteer activities, to include serving as a director and internal auditor of a federal credit union. Thus, while she may have left or been terminated from certain positions, she has nonetheless shown that she is able to obtain successfully obtain additional employment. Accordingly, the Board finds that the probative evidence of record shows that symptoms of the Veteran’s PTSD did not cause occupational and social impairment with deficiencies in most areas or total occupational and social impairment during this period on appeal. In reaching such conclusion, the Board affords less probative weight to the November 2013 private PTSD DBQ. Here, there is no indication that Dr. D.A. reviewed the Veteran’s claims file, including her previous treatment records, and all findings included in the questionnaire appear to be based upon the Veteran’s self-reported medical history. Significantly, such findings are directly contradicted by the VA and private treatment records, as well as all VA examinations conducted during the appeal period. In contrast, the Board affords great probative weight to the December 2013 and April 2015 VA examinations of record. In this regard, the December 2013 VA examination was completed shortly after the November 2013 private DBQ, and both VA examinations were conducted by examiners with the appropriate expertise in evaluating psychiatric disabilities, who, following a review of the Veteran’s claim file, provided detailed descriptions of the impact the Veteran’s PTSD had on her social and occupational functioning. Here, the descriptions of the functional impact of the Veteran’s PTSD are consistent with those reflected in the VA and private treatment records during the appeal period. In this regard, the December 2013 VA examination report reflects that the Veteran’s PTSD had been manifested by occupational and social impairment due to mild or transient symptoms, which is commensurate with a 10 percent rating under the General Rating Formula and, the April 2015 VA examination report reflects that the Veteran’s PTSD had been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, which is commensurate with a 30 percent rating under the General Rating Formula. Thus, such more nearly approximates her disability rating of 50 percent during the appeal period rather than that of 70 or 100 percent. Furthermore, with respect to the SSA’s June 2013 determination, such was based on the same evidence reviewed by the Board. Nonetheless, the Board finds that SSA’s evaluation of this evidence, while probative, does not outweigh the Board’s interpretation of the medical evidence prior to October 16, 2018, as the agencies have different disability determination requirements. Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (indicating the SSA’s favorable determination, while probative evidence to be considered in the claim with VA, is not dispositive or altogether binding on VA since the agencies have different disability determination requirements). As such, a rating in excess of 50 percent for such disability prior to October 16, 2018, is not warranted. Similarly, the Board finds that, a rating in excess of 70 percent for PTSD, for the appeal period since October 16, 2018, is not warranted. Specifically, there is no evidence that the Veteran’s PTSD results in symptomatology of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Furthermore, while an intermittent inability to perform activities of daily living, and suicidal and homicidal ideation were noted, the Board finds that the frequency, duration, and severity of such symptoms do not result in total occupational and social impairment. Further, while the Veteran is in receipt of a TDIU since October 16, 2018, due to her PTSD, the record fails to show that such results in total social impairment, as she continues to maintain relationships with her children and long-term friend, and the assignment of a 100 percent rating for PTSD requires both total occupational impairment and total social impairment. The Board acknowledges that the October 2018 VA examiner reported an inability to differentiate the symptoms between the Veteran’s PTSD and her ADHD as the symptoms of the disorders as such had developed in association with one another. Similarly, the examiner found that she could not determine what level of occupational and social impairment was caused by each. Accordingly, the Board finds that the Veteran’s total psychological picture caused social and occupational impairment with deficiencies in most areas since October 16, 2018. Therefore, the Board finds that the Veteran’s symptomatology is most consistent with a 70 percent rating for the appeal period since October 16, 2018. The Board has considered whether additional staged ratings under Fenderson, supra, are appropriate for the Veteran’s service-connected PTSD; however, the Board finds that her symptomatology has been stable throughout the periods on appeal. Therefore, assigning additional staged ratings for such disability is not warranted. Further, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, in connection with her initial rating claim. Doucette v. Shulkin, 28 Vet. App. 366 (2017). In sum, the Board finds that an initial rating in excess of 50 percent prior to October 16, 2018, and in excess of 70 percent thereafter for the Veteran’s PTSD is not warranted. In denying higher ratings, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a TDIU prior to October 16, 2018. The Veteran has been awarded a TDIU as of October 16, 2018, but she asserts that her service-connected PTSD prevented her from securing and following a substantially gainful occupation prior to such date. Specifically, she argued in a February 2021 statement that a TDIU should have been granted as of May 15, 2013, the effective date of the award for service connection for PTSD as she was unable to work, homeless, and highly symptomatic due to such disability. 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). “Substantially gainful employment” is considered “work that involves doing significant productive physical or mental duties and is done for pay and profit” even if the work “is done on a part-time basis or if a claimant is paid less, or is given less responsibility that when the same claimant worked before.” In other words, “substantially gainful occupation” is “one that provides annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the veteran actually works and without regard to the veteran’s earned annual income” prior to when he was last employed. See Faust v. West, 13 Vet. App. 342, 356 (2000) (citing analogous Social Security Administration Regulations). Marginal employment generally shall be deemed to exist when a veteran’s earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16(a). Marginal employment may also be held to exist, on a facts found basis (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. Consideration shall be given in all claims to the nature of the employment and the reason for termination. Id. In this regard, the Court has indicated that factors to consider in determining whether a protected work environment exists may include the “magnitude of the veteran’s job responsibilities and the degree of accommodation necessary for successful, full-time work.” Cantrell v. Shulkin, 28 Vet. App. 382, 392 (2017). Additionally, in Judge Lance’s concurring opinion, it was noted that where a veteran’s disabilities do not result in lost income or where legally required accommodations permit a veteran to maintain gainful employment, an award of TDIU does not serve its intended purpose. Id. at 396. 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); Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran’s 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran’s master’s degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court defined the term “unable to secure and follow a substantially gainful occupation” in § 4.16(b) to include two components: one economic and one noneconomic. The economic component means 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. The non-economic component includes consideration of the veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Although VA did not receive the Veteran’s Application for Increased Compensation Based on Unemployability (VA 21-8940) until October 19, 2018, the Board has assumed jurisdiction over the issue of entitlement to a TDIU prior to October 16, 2018, as part and parcel of her claim for a higher initial rating for PTSD, which stems from May 15, 2013, the date of service connection for such disability. Rice v. Shinseki, 22 Vet. App. 447 (2009); Harper v. Wilkie, 30 Vet. App. 356 (2018). For the period prior to October 16, 2018, the Veteran’s PTSD is rated as 50 percent disabling; her cough-variant asthma is rated as 10 percent disabling; her TMJ dysfunction is rated as 10 percent disabling; and her hypertension and muscle contraction tension headaches are both rated as noncompensably disabling. Thus, her combined disability rating is 60 percent from May 15, 2013, until October 16, 2018; however, as her cough-variant asthma, TMJ dysfunction, hypertension, and headaches have been related to her PTSD, all disabilities share a common etiology and, thus, are considered one for TDIU purposes. 38 C.F.R. § 4.16(a). Therefore, the Veteran meets the schedular threshold for consideration of a TDIU for the relevant period. Consequently, the remaining inquiry is whether such disabilities render her unable to secure or follow a substantially gainful occupation consistent with her education and work history. As pertinent to the Veteran’s education, the record reflects that she has a Bachelor of Arts, Executive Graduate Certificate in business administration, and Masters of Business Administration. She also had additional training towards project management professional credentialling certification and business analysis, and completed all the requirements for a Ph.D. in business administration, with the exception of the dissertation; however, in December 2020, she reported that she was returning to school. Furthermore, in her December 2016 resume, she reported that she is proficient with a multitude of computer-based applications. As pertinent to the Veteran’s work history, while she asserts that she became too disabled to work as of May 15, 2013, she indicated on her Veteran’s Application for Increased Compensation Based on Unemployability (VA Form 21-8940) that she worked part-time in teaching/counseling from September 2010 to June 2013, which was described as teaching adult education and providing employment counseling, and January 2017 to August 2018, and worked full-time in a technical/analysis position from November 2014 to April 2015, which was described as a veterans service representative at VA, and from June 2015 to August 2018, which included a wide variety of administrative tasks performed at the Department of Commerce, Bureau of Census. In this regard, such demonstrates that, with the exception of the periods from June 2013 to November 2014, April 2015 to June 2015, and August 2018 to October 2018, the Veteran reported that she was employed on a full-time basis throughout the appeal period. Moreover, while not reported on her VA Form 21-8940, evidence developed through the Veteran’s 2016 and 2018 applications for VA vocational rehabilitation benefits reflect additional paid and volunteer positions that demonstrate her ability to perform the physical and mental acts necessary for substantial gainful employment for the appeal period prior to October 16, 2018. Specifically, resumes received in December 2016 and June 2018 reflect that, from May 2014 to April 2017, the Veteran served as the appointed director and, from May 2017 through at least June 2018, an internal auditor for a federal credit union on a volunteer basis, and worked as a business consultant for an automotive company through January 2014. Furthermore, she reported starting her own company in March 2012, which was still open as of June 2018, where she served as the principal business strategist/CEO. Moreover, from March 2017 through at least June 2018, she served as an adjunct faculty member at Wilmington University where she taught a course in the undergraduate business management program. See December 2016 & June 2018 resumes. Thus, even though she was not formally employed during certain periods on appeal, it is clear that the Veteran continued to successfully engage in business-related activities, thereby demonstrating that, despite any functional impairment from her service-connected disabilities, she was able to perform the physical and mental acts necessary to secure and maintain substantially gainful employment. Furthermore, while the Veteran reported missing between four to five days per month to several weeks per year from 2014 until 2018, to include through using the maximum time of leave allowable under Family and Medical Leave Act (FMLA) for 2016, 2017, and 2018, the Board finds that, despite the use of such accommodation, her job responsibilities were not reduced such that her employment was not marginal in nature. See Cantrell, supra, at 392. Furthermore, as addressed in Judge Lance’s concurring opinion, where a veteran’s disabilities do not result in lost income or where legally required accommodations permit a veteran to maintain gainful employment, an award of TDIU does not serve its intended purpose. Id. at 396. Furthermore, while the Veteran’s work performance declined over time, to include receiving a less than satisfactory evaluation in February 2018, she continued to maintain such position through August 2018, and engaged in additional professional and volunteer activities through October 2018. With respect to the functional impairment associated with her service-connected disabilities, the December 2016 and June 2018 vocational rehabilitation counselors noted that the Veteran’s PTSD symptoms included intermittent irritability, depression, short-term memory issues, anxiety, and sleep disturbances, and the Veteran denied any vocational impairment associated with her asthma, hypertension, headaches, and TMJ dysfunction. Thus, they determined that the Veteran would be unable to work in a setting that would cause extreme anxiety, rotating shifts, or complex memory recall. It was further noted that the Veteran was presently employed in several suitable positions, as described above, which were found to be consistent with her interests, aptitude, and capabilities. In light of such, the vocational rehabilitation counselors found that she had overcome her impairment to employability as her employment was stable, compatible with her disability condition, and consistent with her interests, aptitude, and capabilities, and she had no employment handicap. Furthermore, as previously discussed, the Veteran’s PTSD, with symptoms of depressed mood, anxiety, panic attacks occurring weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and mild memory loss, has been determined to result in, at most, occupational and social impairment with reduced reliability and productivity during the appeal period. In this regard, such level of impairment is consistent with the Veteran’s report in her December 2016 application for vocational rehabilitation benefits that she had difficulty with her memory, which increased her stress level, which then triggered panic attacks and exacerbated her ADHD, and October 2018 VA Form 21-8940 that her work performance declined due to her PTSD symptoms of nightmares, anxiety, depression, rage, and panic attacks, which, over time, increased in severity to the point where she could not work. In this regard, the Board notes that such report is consistent with the assignment of a 70 percent rating for PTSD and TDIU as of October 16, 2018. Moreover, while the Veteran reported that she had periods of exacerbations of her PTSD while working, to include in February 2017 when she became enraged at her supervisor, she nonetheless maintained her employment and did not leave such position for a year and a half. In fact, she subsequently obtained new positions, to include an adjunct professor at a university in March 2017 and an internal auditor at a federal credit union in May 2017. Further, as previously noted, while SSA found that the Veteran was disabled from June 30, 2013, to November 30, 2014, due to her affective/mood and anxiety disorders, SSA factored in the Veteran’s nonservice-connected ADHD and recognized that the Veteran’s difficulty with attention caused her anxiety and, in turn, inability to focus, which in part led to the finding of disability during such period. Furthermore, VA examinations conducted in September 2017 reflect that the Veteran’s asthma and TMJ dysfunction had no impact on her ability to work. Also, the examiner indicated that, while the Veteran could not engage in very physically demanding work due to her hypertension, such disability did not preclude her from performing her current job as a survey statistician. Further, while the examiner acknowledged that the Veteran had been provided an accommodation to work from home two days a week due to her headaches, he nonetheless found that, even when working at the office, her headaches only made her less efficient on certain days and she was still able to continue to do her required work despite the presence of a headache. Accordingly, the Board finds the probative medical evidence does not show the Veteran’s service-connected disabilities, either alone or in combination, were of sufficient severity so as to render her incapable of performing the physical and mental acts required by substantially gainful employment during the pertinent period. In reaching such determination, the Board affords great probative weight to the VA vocational rehabilitation counselors’ assessments as such were made by experts in the field who considered the Veteran’s education, work history, and limitations associated with her service-connected disabilities, and the VA examiners’ opinions regarding the functional impact of the Veteran’s service-connected disabilities as such were based on pertinent examinations, a review of the record, and her own reports of her limitations. Thus, the Board finds the Veteran’s service-connected disabilities did not render her unable to secure or follow a substantially gainful occupation consistent with her education and work history prior to October 16, 2018. As the preponderance of the evidence is against her claim, the benefit of the doubt doctrine is not applicable and a TDIU prior to October 16, 2018, is not warranted. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Breckenridge, 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.