Citation Nr: 21027293 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 15-41 574 DATE: May 5, 2021 ORDER Entitlement to a disability evaluation in excess of 50 percent for the service-connected other trauma and stressor related disorder (previously rated as PTSD) from prior to July 18, 2019 is denied. Entitlement to a disability evaluation in excess of 70 percent for the service-connected other trauma and stressor related disorder since July 18, 2019 is denied. Entitlement to a total disability rating for compensation based on unemployability of the individual prior to July 18, 2019 is denied. FINDINGS OF FACT 1. Prior to July 18, 2019, the Veteran's service-connected trauma related disorder was manifested by occupational and social impairment with reduced reliability as a result of psychiatric symptomatology, without more severe manifestations that more nearly approximated a 70 percent rating. 2. Since July 18, 2019, the Veteran's service-connected trauma-related disorder has been manifested by occupational and social impairment with deficiencies in most areas as a result of psychiatric symptomatology, without more severe manifestations that more nearly approximate total occupational and social impairment. 3. The probative evidence of record does not establish that the Veteran's service-connected disabilities render him unable to secure and follow a substantially gainful occupation consistent with his educational and occupational background for the period of appeal prior to July 18, 2019. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for the Veteran's service-connected trauma-related disorder have not been met prior to July 18, 2019. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9410. 2. The criteria for entitlement to a disability rating in excess of 70 percent for the period since July 18, 2019 have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.2, 4.3, 4.7, 4.15, 4.130, Diagnostic Code 9410. 3. The criteria for entitlement to TDIU prior to July 18, 2019 have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.321, 3.340, 3.341, 3.400, 4.3, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the United States Army from August 1986 to February 1990 and December 1990 to July 1991. He is a veteran of the Persian Gulf War. This matter comes to the Board of Veterans' Appeals (Board) on appeal of a December 2014 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In August 2018, the Board remanded the issue on appeal for additional development, and the case has since been returned for further appellate review. A remand by the Board confers on the claimant a legal right to substantial compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). The Board's August 2018 remand directed the RO to obtain outstanding private and VA treatment records. Pertinent records were associated with the claims file. The Board's remand also instructed the RO to provide the Veteran with a VA examination to determine the effects of his service-connected disabilities on his ability to secure or maintain substantially gainful employment and readjudicate the TDIU claim with consideration of new evidence received. Opinions were obtained in October and December 2020, and the Veteran's claims were readjudicated by the RO in January 2021. As such, substantial compliance with the Board's remand was achieved. Id. at 271. In communication received March 2021, the Veteran contends he is entitled to a 70 percent evaluation with an effective date of January 2007 for his service-connected psychiatric disorder. By way of history, the Veteran first filed a claim for PTSD in January 2007 and was granted service connection with an initial 50 percent evaluation. The Veteran appealed that decision, seeking a higher initial rating, which the Board denied in February 2012. The Veteran did not appeal the Board's decision to the United States Court of Appeals for Veteran's Claims (Court), and therefore the Board's decision became final and the period of the appeal closed. The Veteran filed a new claim for an increased rating for his psychiatric disability in August 2013, which was denied in December 2014. The Veteran timely filed a notice of disagreement with that decision, and this appeal ensued. The Board remanded the appeal in August 2018. Following remand, the Veteran was granted a 70 percent rating evaluation in a January 2021 rating decision, effective July 18, 2019 (the date of a VA examination). However, as this does not represent a full grant of the benefit sought, the appeal from his August 2013 claim continues. Therefore, the issue currently before the Board regarding his psychiatric disability is whether the Veteran's symptoms warrant a higher evaluation for the period of the appeal, August 8, 2013 to the present. The January 2021 rating decision also granted the Veteran's claim for TDIU, effective July 18, 2019. The Veteran's correspondence also asserts he is entitled to an earlier effective date for his award of TDIU. The Veteran's claim stems from his August 2013 request for an increased rating. The Board addresses the appropriate effective date below. Increased Disability Evaluations Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions 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; or memory loss for names of close relatives, own occupation or own name. The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Id. The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. 1. Entitlement to a rating in excess of 50 percent for psychiatric disability prior to July 18, 2019. The Veteran's psychiatric disorder was originally diagnosed as post-traumatic stress disorder (PTSD), with an evaluation under Diagnostic Code 9411 of 50 percent, effective January 31, 2007, the date of his initial claim. At mental health evaluations in October 2014 and February 2017, the examiners concluded the Veteran's symptoms had improved and provided a new diagnosis. As such, in the December 2014 rating decision on appeal, the service-connected disability was recharacterized and the diagnostic code was updated. See 38 C.F.R. § 4.125(b). Specifically, the Veteran's psychiatric disorder is currently characterized as other trauma and stress related disorder, and is evaluated under Diagnostic Code 9410. The 50 percent evaluation was continued, until an increase to 70 percent was granted, effective July 18, 2019. Thus, the Veteran has a staged rating. Each stage is discussed here. The Board concludes that for the first period on appeal (from August 2013 to July 2019), the Veteran's symptoms did not cause the level of impairment required for a disability rating in excess of 50 percent. Rather, the Veteran's symptoms resulted in a level of impairment that most closely approximated impairment associated with a 50 percent rating. The Veteran received periodic mental health treatment from his psychiatrist, Dr. HJ, from 2007 until 2015. A record dated August 2013 shows the Veteran presented with a constricted affect, but no suicidal or homicidal ideations, and no auditory or visual hallucinations. March 2014 records show an increase in restlessness, tension, and hyper arousal with a blunted affect and psychomotor retardation. In November 2014, the Veteran reported symptoms of anxiety, depression, and hyper arousal, and it was noted he was not socializing and demonstrated obsessive thoughts about being safe. At an August 2015 session, the Veteran had a blunted affect with thought blocking, word searching, and delayed thought and reported having difficulty being in crowds. Dr. HJ noted no pressured speech, flight of ideas, hallucinations, or injurious behavior. Throughout his private treatment, the Veteran denied thoughts of suicidal or homicidal ideation, paranoia, delusions, and auditory and visual hallucinations. The Veteran began to receive mental health treatment at VA clinics in 2014. A December 2014 psychology note indicates the Veteran experienced relationship and employment stressors but concludes he retained positive coping and problem-solving skills and maintained a therapeutic relationship. At the Veteran's October 2014 VA examination, the Veteran's symptoms were reported as difficulty sleeping, occasional nightmares, hypervigilance, anger/irritability, and hyper startle response. He had an agitated affect and described his mood as "kind of wacky." Although the Veteran believed his symptoms had worsened, the examiner indicated he reported fewer symptoms than at his initial evaluation and showed improvement even though he received minimal mental health treatment since 2009. The examiner noted his symptoms were mild, resulting in mild difficulty in social and occupational functioning, although he was functioning quite well and maintained good relationships. The examiner utilized reliability testing for malingering that resulted in a score twice the normal cut off. She opined the Veteran was at least mildly embellishing symptoms and further symptom gauges were not appropriate. She concluded the Veteran's symptoms were largely due to characterological features of his personality and poor behavior controls rather than clinical symptoms, though she declined to provide a separate diagnosis at that time. At his initial VA mental health assessment in September 2015, the Veteran reported nightmares, irritability, mood swings, startle response, and hypervigilance. At follow up treatment in August 2016, the Veteran stated his symptoms remained the same with slight improvement in the number of hours of sleep. At the Veteran's February 2017 VA examination, the examiner noted the Veteran's diagnoses of other trauma/stressor related disorder and alcohol use disorder. He reported his symptoms were avoidance reactions, hyperarousal, hypervigilance, poor sleep patterns, trouble concentrating, pessimism, high startle, and loss of interest. Associated symptoms were also listed as were anxiety, depression, suspiciousness, difficult establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and he presented with a flat affect with poor range. The examiner noted his thought processing was intact and his insight and judgment were fair. She concluded the Veteran presented with symptoms that resulted in occupational and social impairment with reduced reliability and productivity. She determined the Veteran's symptoms could not be differentiated between his alcohol use disorder and his stress disorder because substance use can cause mood problems, anger, and irritability which has symptom overlap with his stress disorder. She concluded there was no change in his diagnosis. January 2018 mental health treatment shows the Veteran reported slightly less nightmare occurrence and an increase in hours of sleep since his last treatment. He still experiences irritability, mood swings, and hypervigilance. There is no indication of suicidal or homicidal ideation and the Veteran noted having a part-time job at a convenience store. A follow up assessment in November 2018 shows he experienced nightmares, irritability, anger, anxiety, hypervigilance, and a belief he hears and sees things that are not real. However, the examiner indicates there are no auditory or visual hallucinations or paranoia present. Mental health outpatient treatment in May 2019 shows the Veteran reported symptoms of mood swings, irritability, nightmares, and seeing things at nighttime. He indicated he feels more anxious and startles easily. The Board finds the Veteran's disability picture prior to July 18, 2019 is most consistent with a 50 percent rating, with social and occupational impairment with reduced reliability and productivity as a result. The above-cited evidence reflects that the Veteran's psychiatric disorder was manifested by: nightmares, depressed mood, anxiety, sleep impairment, hypervigilance, and avoidance behavior. While the October 2014 examiner noted the Veteran continued to maintain good relationships, the record demonstrates the Veteran consistently shows avoidance behavior and withdrawal. Collectively these symptoms are of the type, extent, severity, and frequency to result in occupational and social impairment with reduced reliability and productivity. A rating greater than 50 percent is not appropriate because the evidence of record does not indicate that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as contemplated by the 70 percent rating criteria. The Veteran has consistently denied suicidal ideation throughout the record as evidenced by his VA and private treatment records. Furthermore, there is no mention in the record of obsessional rituals, illogical speech, spatial disorientation, neglect of hygiene or personal appearance, or other symptoms related to a level of severity contemplated by those symptoms. Based on these facts, the Board finds that the probative evidence shows the Veteran's symptoms most closely approximate the criteria for a 50 percent disability rating under the General Rating Formula for Mental Disorders. Accordingly, the Veteran's claim for an increased rating prior to July 18, 2019 is denied. 38 U.S.C. § 5107 (b). 2. Entitlement to a disability rating in excess of 70 percent after July 18, 2019 The Veteran contends his psychiatric symptoms warrant an evaluation higher than 70 percent for the period following July 18, 2019. Therefore, the question for the Board is whether the Veteran's associated symptoms for the period following July 18, 2019 caused the level of impairment required for a disability rating of 100 percent. The Board concludes that for period on appeal from July 19, 2019 to the present, the Veteran's symptoms did not cause the level of impairment required for a disability rating of 100 percent and more closely approximates and results in a level of impairment associated with a 70 percent rating. A July 2019 VA opinion, concluded the Veteran's symptoms resulted in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and mood. The examiner indicated the Veteran's behavior was not appropriate for an office setting; he was irascible, loud, and yelling. His symptoms were reported as avoidance reactions, hyperarousal, poor sleep patterns, loss of interest and motivation, and feeling detached from others. The Veteran's insight and judgment were poor and he reported a recent verbal altercation with a pedestrian, indicating a lack of impulse control. The Veteran's rating was increased from 50 to 70 percent based on this evidence. However, subsequent VA treatment records do not establish the Veteran experiences symptoms associated with a 100 percent rating such as persistent delusions or hallucinations, gross impairment of thought processes or communication, disorientation to time or place, persistent danger of harming self or others, memory loss, intermittent inability to perform activities of daily living, or other manifestations on par with the level of severity contemplated by those symptoms. Rather, the evidence shows that the Veteran's trauma and stressor related disorder is manifested by symptoms associated with a 70 percent rating including: impaired impulse control, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. VA treatment records from August 2019 show the Veteran retained good insight, judgment, and concentration. No hallucinations, obsessions, suicidal or homicidal ideations, or psychotic symptoms were noted. Memory was grossly intact, thought processes were coherent, linear, and goal-oriented, and the Veteran was alert and oriented in all spheres. He reported mood swings, anger, irritability, feeling anxious or depressed, startle response, and experiencing flashbacks. Testing revealed a minimal positive score for depression and a negative score for suicide risk. March 2020 mental health records reveal the Veteran's judgment, insight, and concentration was good with normal psychomotor activity. The Veteran reports his symptoms did not improve since his last visit, but does not indicate worsening of existing symptoms or development of new symptoms. An April 2020 routine health follow-up shows the Veteran was observed to be well-orientated, well-communicative, with normal mood and clear speech. Depression and suicide screenings were both negative and the Veteran was noted to answer questions appropriately. In a June 2020 mental health note, the Veteran reported doing "fine", sleeping four to six hours a night, nightmares two to three times a week, mood swings, and depressed feelings. He reported no suicidal or homicidal ideations and his concentration, insight, judgment, and speech were reported as good. The examiner noted the Veteran's mood was withdrawn, but had a normal rate of speech and had an appropriate affect. Recurring symptoms such as flashbacks, depression, mood swing, and sleep disturbance persisted, however, absent from his report of symptoms is irritability, anger, anxiety, and startle response. In an unrelated September 2020 neurology consultation, the Veteran is reported to be alert and oriented, a good historian with appropriate answers to questioning, with good affect and general conversation presentation. The Board finds the Veteran's symptoms are more consistent with a 70 percent rating with symptoms of nightmares, depressed mood, anxiety, sleep impairment, hypervigilance, and avoidance behavior. The evidence overall does not demonstrate the level of impairment associated with a 100 percent rating for the period following July 19, 2019. The medical evidence represents a stable presence of symptoms rather than an increase in frequency, severity, or duration. Additionally, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. There is no evidence of record that establishes that the Veteran experiences 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; disorientation to time or place; memory loss for names of close relatives, occupation, or own name; or other symptoms on par with the level of severity contemplated by these symptoms. While the July 2019 examiner noted the Veteran displayed grossly inappropriate behavior and judgment, subsequent treatment notes indicate the Veteran has good insight, judgment, psychomotor activity, and concentration. The record shows the event is not consistent with the rest of the evidence of record and the Veteran has been consistently able to communicate effectively with his VA providers. He was shown to have a good affect in September 2020 with good conversation presentation. There is no mention in the record of obsessional rituals, spatial disorientation, or an inability to perform daily tasks and activities due to his disability such as a neglect of personal hygiene as he was found to be functioning well and improving with medication. Furthermore, there is no indication he has other symptoms related to a level of severity contemplated by those symptoms. He continues to deny suicidal ideation throughout the record and has not been found to be a threat to himself or others as evidenced by recent VA treatment records. Thus, his symptoms are not of similar frequency, severity, and duration of those consistent with the maximum, 100 percent, disability rating. The overall disability picture demonstrated by the evidence is not consistent with a higher disability rating. The maximum rating for this disability is not warranted as it has not shown to cause total social and occupational impairment. While the Veteran displays withdrawal and avoidance of others, he has not shown to demonstrate a total impairment in social relationships. The Board notes that the Veteran was awarded TDIU, effective July 19, 2019, based on the cumulative impact of his service-connected disabilities, and not on any one particular issue. As such, an award of TDIU cannot serve to establish a total disability rating for any singular disability. Akles v. Derwinski, 1 Vet. App. 118 (1991). The Board finds the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. As the criteria for a 100 percent are not met, the appeal must be denied. 3. Entitlement to a total disability rating for compensation based on unemployability of the individual prior to July 18, 2019 The Veteran is currently in receipt of a total disability rating based on individual unemployability (TDIU) for the period following July 18, 2019. He contends the symptoms related to his psychiatric disorder have rendered him unable to obtain and maintain gainful employment since January 2013, the date of his last full-time employment. See Statement in Support, 3/16/2021. A total disability rating may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or 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). The Veteran is currently service connected for: (1) Berger's disease with hypertension, rated as 30 percent disabling, effective December 15, 1993; (2) erectile dysfunction rated as noncompensable, effective February 28, 2007; (3) post-traumatic stress disorder, rated as 50 percent disabling effective January 31, 2007 to August 8, 2013; and (4) other trauma and stressor related disorder, rated as 50 percent disabling from August 8, 2013, and 70 percent disabling effective, from July 18, 2019. The Board notes Veteran's combined evaluation was 80 percent from August 2013 to July 2019, and 80 percent thereafter. Thus, the Board finds that the Veteran meets the threshold for schedular criteria of entitlement to a TDIU for the entire period on appeal. VA regulations provide that in increased rating claims, as well as claims for TDIU, the effective date of an award is either the date the claim is received or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400 (o)(1). This general rule has an important exception that provides: the effective date will be the "[e]arliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred if a complete claim or intent to file a claim is received within 1 year from such date, otherwise, [the effective date is the] date of receipt of the claim." 38 C.F.R. § 3.400 (o)(2). The Veteran's claim was received on August 8, 2013, thus the relevant period begins 1 year prior to that date. If the record contains evidence of an increase in disability occurring within that period, the Veteran is eligible for an earlier effective date for the grant of a TDIU. Therefore, the question before the Board is whether his service-connected disabilities precluded the Veteran from securing and following a substantially gainful occupation for the period of August 8, 2012 to July 19, 2019. See 38 C.F.R. § 4.16(a). In general, a finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. The central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In reaching a determination of TDIU, the fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The fact finder must determine whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Beaty v. Brown, 6 Vet. App. 532, 538 (1994). Consideration must be given to the type of employment for which the veteran would be qualified with review of education level, special training, and previous work experience. However, advancing age and impairment caused by nonservice-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000). Although the Veteran filed his TDIU claim based on his psychiatric disability, the AOJ obtained medical opinions regarding whether the Veteran's non-psychiatric service-connected disabilities cause occupational limitations. In August 2019, the medical examiner opined the Veteran's erectile dysfunction and hypertension caused "no limitations for employability." Another opinion was provided in October 2020, concluding "there are no occupational limitations" for the Veteran's hypertension secondary to Berger's disease. The Veteran's Berger's disease is managed with medication and there is no indication it causes any limitations on employability. The Board concludes the Veteran's service-connected non-psychiatric disabilities do not cause limitations to employability and the remainder of the analysis will focus on his psychiatric disability. The record demonstrates the Veteran applied for TDIU in December 2008. He reported having two years of college education but became unable to work due to his disabilities in November 2008. In a more recent application for unemployability completed in August 2013, he reported he last worked full time and become too disabled to work in January 2013. He indicated he had four years of college education and last worked in technical phone support. The Veteran submitted a Statement in Support of his claim for TDIU in September 2014. He stated he was unable to work due to his mental health condition and that he was unable to complete the VA's Vocational Rehabilitation and Employment program (VR&E) due to his psychiatric disabilities. However, the claims file shows the Veteran began the vocational program in April 2008 and was deemed "Job Ready" in November 2011, completing the program. See VR&E, 10/9/2017, pg. 350/420. The purpose of the program was to provide the Veteran with the entry level skills necessary to obtain suitable employment as he believed he could not obtain a position due to his lack of education and PTSD. During that period, he earned a Bachelor of Science degree in Information Systems with a concentration in Networking. Records indicate he graduated with a 3.0+/4.0 GPA in September 2011. The Veteran reported he did not experience difficulty with non service-related disabilities including fatigue, respiratory condition, tinea versicolor, and insomnia. An employment coordinator found the Veteran's service-connected conditions did not clearly provide functional limitations and were not a substantial contribution to his employability. However, he was found to be limited in his ability to perform work that requires managing the mental health and socioemotional needs of others. He expressed displeasure with his position as a computer help desk technician responsible for maintaining lengthy conversations with disgruntled customers in an attempt to reconcile computer issues. The Veteran set the program goal of obtaining a position as a database manager or computer systems analyst and indicated that such employment would not aggravate limitations associated with his service-connected disabilities. His vocational Case Closure Statement indicates the Veteran did not maintain contact with program coordinators and did not respond to attempts to reach him by telephone, e-mail, or postal mail. Over the next several years, he was shown to obtain employment in the technology field but was unable to retain his position for long. As part of the program, the Veteran was provided job openings in February 2013, shortly after his last employment ended. However, he indicated he did not wish to work as an information systems specialist or help desk analyst. Several more opportunities were given to the Veteran without responsibilities in customer service. A VA letter from March 2013 reveals the Veteran's program would be interrupted as he had failed to maintain contact with his case manager or responded to recent communications. VA and North Carolina Department of Commerce (NC DOC) coordinators contacted the Veteran in May and June 2013 to offer nearby employment opportunities. There is no indication the Veteran responded to the outreach. NC DOC employment coordinators reached out to the Veteran several times in May 2014 to offer services in locating job opportunities. An internal memo indicates the NC DOC did not receive a return call from the Veteran. When VA coordinators reached the Veteran to offer assistance in September 2014, he informed the case worker he wanted his case "closed, burned, or whatever" and did not want to be contacted by VA again. The employment coordinator determined the maximum rehabilitation gain had been achieved for the Veteran, and NC DOC coordinators similarly ceased attempts to engage with him concerning employment assistance. He was found "Job Ready" in September 2014 when his participation in the vocational program ceased. Although the question of unemployability is ultimately a legal determination for the trier of fact, as opposed to a medical finding, there are probative medical opinions of record. See, Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). At his October 2014 psychological evaluation for his increased rating claim, the psychologist noted the Veteran had not worked since 2013 but that he reported he was not currently seeking employment. See C&P, 10/9/2014, pg. 5/11. As stated above, the examiner concluded the Veteran's difficulties and reported symptoms may be due to characterological features of his personality and poor behavioral control, such as antisocial features, poor sleep hygiene, and excessive alcohol use, rather than clinical symptoms. The examiner concluded the Veteran was a fair to questionable informant as he scored double the typical cut off in his reliability questionnaire and the examiner deemed other gauge testing was inappropriate for this Veteran. At that time, the Veteran's symptoms were best characterized as mild such that they result in mild difficulty in social and occupational functioning. Accounting for the Veteran's reliability, the examiner found his general functioning well and interpersonal relationships meaningful. The examiner also indicated some of his symptoms are better described as longstanding personality traits or sub-clinical symptoms exacerbated by alcohol use. The examiner also noted the Veteran had no difficulty completing school work or occupational skills. He concluded the Veteran's employment impairment due to his psychiatric disorder was "occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks, although he is generally functioning well with normal routine behavior, self-care, and conversation." The examination is highly probative as it provides a full disability picture for this Veteran. The examiner provided an extensive review of the Veteran, covering his education, employment history, and claims file. His conclusions are supported by sound reasoning, testing methods, and thorough analysis of his psychiatric disability and related symptoms. Prior to completing his bachelor's degree in information technology, the Veteran worked as a janitor, landscaper, DJ, truck driver, and as a forklift driver for nine years. Although he was able to secure jobs in technology, in 2011 the Veteran reported he did not want to take any more positions that paid $13 per hour (the equivalent of $15.20/hr today). The Veteran has also reported earning a salary up to $47,000 annually. VA 21-8940, 8/8/2013. Each employment role he has obtained, since at least 2008, has been a full-time position. There has been no allegation that the only work available to the Veteran is marginal employment, such that earned income does not exceed the poverty threshold for one person. 38 C.F.R. § 4.16(a). Given this evidence and the nature of his employment history, the Board does not find marginal work to be at issue. In order to establish entitlement to TDIU, there must be impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. The remainder of the evidence weighs against such a finding. The Veteran has consistently asserted his psychiatric disorder limits him from being sociable and forces him to avoid crowds. The Veteran reports most often that his disorder causes him to become "upset when people don't understand me" and trouble tolerating difficult people, particularly during high-volume call periods. However, he has not otherwise described other occupational impacts due to his psychiatric disorder and the medical evidence does not indicate his service-connected disabilities alone render him unemployable. Occupational and social limitations the Veteran experiences due to his psychiatric disorder are contemplated in his current rating. See 38 C.F.R. § 4.130, DC 9410. There is also no indication the Veteran does not have the mental ability to perform the activities required by his occupation, nor is there evidence he lacks the physical ability to perform the type of activities required. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). A thorough review of his work history shows the Veteran has held jobs consistent with his abilities, aptitudes, and interests for many years, though for short periods of time and most often in a customer service role. Although the Veteran does not retain his positions for lengthy periods, the evidence supports a conclusion that the Veteran's disabilities do not preclude him from doing so. The Veteran was last employed full time in February 2013. In the various roles he has held, several reasons for termination are provided including: contract end, resignation, lack of work, insubordination, not the right fit for the position, and positive alcohol testing. VA 21-4192, 8/8/2013. The Veteran has some limitations due to his service-connected disabilities, the totality of the evidence shows these limitations are not great as to make employment impossible. The Veteran's February 2019 VA examiner provided an additional diagnoses of alcohol use disorder, which is not currently service-connected. The examiner opined his alcohol use and stress-related disorder have overlapping symptoms, resulting in mood problems, anger, and irritability, such that individual impairment could not be determined. However, the examiner opined the Veteran experienced occupational and social impairment with reduced reliability and productivity, indicating there was no change in his previous diagnosis. In July 2019, the examiner provided a more specific diagnosis of "alcohol use disorder, recurrent, moderate." Due to significant symptom overlap, the examiner concluded she could not determine the individual impact of each diagnosis. She concluded the resulting impairment amounted to "occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." The Board finds both examinations highly probative. As the same psychologist conducted the February and July 2019 examinations, the later conclusion indicates an increase in the Veteran's symptoms. He was found to have difficulty in adapting to stressful circumstances, including work or a work-life setting. The examiner concluded the Veteran's symptoms caused "significant distress or impairment in social, occupations, or other important areas of functioning. Although the Veteran is not currently service-connected for alcohol use disorder, the Board employs the reasonable doubt standard and attributed signs and symptoms to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). As such, the date of the July 19, 2019 examination is the first date it is factually ascertainable the Veteran became unemployable due to his service-connected disabilities. For the forgoing reasons, the Board finds that it is not factually ascertainable that the Veteran became eligible for TDIU; that is, the competent and probative evidence does not support a finding that the Veteran's service-connected disabilities rendered him unemployable prior to his July 19, 2019 effective date. The Board also finds that the competent, probative evidence of record is not so evenly balanced as to warrant application of the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.N. Chapman, 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.