Citation Nr: 21030277 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 12-16 932 DATE: May 18, 2021 ORDER Entitlement to an initial evaluation of 70 percent, but no higher, for service-connected post-traumatic stress disorder (PTSD) with alcohol abuse/dependency is granted. Entitlement to a total disability rating on the basis of individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Resolving any reasonable doubt in the Veteran's favor, throughout the entire timeframe on appeal, his PTSD is manifested by symptoms consistent with occupational and social impairment that involves deficiencies in most areas. 2. The Veteran's service-connected disability does not preclude him from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent disability evaluation, but no higher, for PTSD are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to a TDIU are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.341, 4.3, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service with the Army from March 1966 to February 1969. This matter is before the Board of Veterans' Appeals (the Board) on appeal from a January 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). A June 2012 rating decision provided the Veteran with a partial grant of the benefits sought on appeal. His PTSD with alcohol abuse/dependency was evaluated as 50 percent disabling effective April 1, 2010. As this increase did not constitute a full grant of the benefit sought for the entire appeal period, the Veteran's claim for a higher evaluation remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). As such, the issues on appeal before the Board are for an initial evaluation in excess of 50 percent for service-connected PTSD with alcohol abuse/dependency. The Board remanded the Veteran's claims for additional development in February 2013 and May 2017. The Board most recently denied entitlement to an evaluation in excess of 50 percent for PTSD with alcohol abuse/dependency and a TDIU in July 2018. The matter returns to the Board from a United States Court of Appeals for Veterans Claims (the Court) Memorandum Decision issued in March 2020. The Memorandum Decision vacated and remanded the July 2018 Board decision. The Court noted the July 2018 denial failed to provide an adequate statement of reasons and bases for denying an evaluation in excess of 50 percent for PTSD with alcohol abuse/dependency and entitlement to a TDIU. The Board decision focused on more positive aspects of the Veteran's medical history and the symptoms he did not experience. Additionally, the Board should have considered whether staged ratings were appropriate. Regarding his TDIU claim, the Board noted his difficulty getting along with others but focused instead on his comment about being too old to work. The analysis should have focused instead on his PTSD symptoms. The Board noted he frequently quit jobs but focused on his ability to find a new job. The analysis should have focused instead on whether frequently leaving jobs constituted being able to secure and follow substantially gainful employment. For these reasons, the Court vacated and remanded the July 2018 Board decision for failing to provide an adequate statement of reasons and bases in denying these claims. The Board may not consider additional evidence not previously reviewed by the Agency of Original Jurisdiction (AOJ) unless a waiver of initial AOJ review is obtained from the Veteran. See 38 C.F.R. § 20.1304(c). In April 2018, the RO issued a Supplemental Statement of the Case (SSOC). The Board notes that additional pertinent evidence was received and associated with the claims file since the July 2018 Board decision. In March 2021, the Veteran's representative submitted another VA From 21-8940, a private vocational assessment by B.C., and earning records. Through his representative the Veteran waived RO consideration of this evidence. Therefore, the Board has concluded that it may proceed with appellate consideration of the claims without prejudice to the Veteran. See 38 C.F.R. § 19.31. 1. Entitlement to an initial evaluation of 70 percent, but not more, for PTSD with alcohol abuse/dependency is granted. Applicable Law and Regulations The Veteran is rated under DC 9411, which is rated according to the General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, a noncompensable rating is warranted when a mental condition has been diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication A 10 percent evaluation is warranted if there is 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 continuous medication. A rating of 30 percent is assigned when the Veteran exhibits occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affected 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); and inability to establish and maintain effective relationships. A 100 percent rating is assigned when 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. The evidence considered in determining the level of impairment for psychiatric disorders under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the rating code. Disability ratings are assigned according to the manifestation of particular symptoms, but the use of the term "such as" in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the evidence considered in determining the level of impairment from psychiatric disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in DC 9435. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect some mild symptoms [e.g., depressed mood and mild insomnia] or some difficulty in social, occupational, or school functioning [e.g., occasional truancy, or theft within the household], but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more moderate symptoms [e.g., flat affect and circumstantial speech, occasional panic attacks] or moderate difficulty in social, occupational, or school functioning [e.g., few friends, conflicts with peers or co- workers]. Scores ranging from 41 to 50 reflect serious symptoms [e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting] or any serious impairment in social, occupational, or school functioning [e.g., no friends, unable to keep a job]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication [e.g., speech is at times illogical, obscure, or irrelevant] or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood [e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school]. The VA has changed its regulations, and now requires use of the DSM-V effective August 4, 2014. Among the changes, the DSM-V eliminates the use of the GAF score in evaluating psychiatric disorders. The change was made applicable to cases certified to the Board on or after August 4, 2014; and is not applicable to cases certified to the Board prior to that date. 79 Fed. Reg. 45093. As the Veteran's case was certified to the Board prior to August 4, 2014, the DSM-IV applies. Factual Background and Analysis The Veteran currently has an initial evaluation of 50 percent for PTSD with alcohol abuse/dependency effective April 1, 2010. The Veteran asserts entitlement to a rating in excess of 50 percent for his mental condition. In June 2010, the Veteran underwent a diagnostic interview for his mental impairments. He was assessed with re-experiencing intrusive thoughts, exhibiting avoidance behavior (isolation and emotional numbing), hyperarousal, and alcohol dependence. His mental status examination found him cooperative with appropriate speech. He was oriented, had a normal memory, appropriate affect, relaxed motor activity, fair judgment, and no evidence of suicidal or homicidal ideation. His appearance was neat. In a December 2010 VA examination for PTSD, he was observed to be appropriately dressed. He was fatigued and tense. His speech was clear and coherent. The Veteran had a constricted affect, dysphoric mood, short attention span, and only partial insight. However, he retained normal memory and an unremarkable thought process. He had persistent re-experiencing of traumatic events, avoidance of stimuli, and increased arousal (i.e., difficulty falling/staying asleep, irritability, outbursts, hypervigilance). He had chronic moderate PTSD symptoms, which caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. He worked successfully alone for many years. Although he reported a positive family environment, he also reported having few friends and hobbies. He struggled with sobriety. He reported an inability to interact with others since the war and struggled with isolation. Overall, the signs and symptoms of his PTSD were assessed to be transient or mild causing decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. He struggled with daily efficiency and productivity based on his mood and stress level. He engaged in isolating and avoidance behavior that effect his problem-solving ability. There did not appear to be evidence of occupational impairment. The December 2010 examiner's opinion found both chronic moderate PTSD symptoms, which would cause clinically significant functional impairment and transient or mild symptoms causing decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner's assessment provides conflicting findings as to the severity of the Veteran's condition. Therefore, the December 2010 opinion was accorded little probative weight. W.A. (Psy.D.) provided private psychological evaluations of the Veteran in February 2011 and February 2013. The Veteran reported difficulty making friends after his separation from service. He had a number of acquaintances but was only emotionally close with his wife and daughters. He had anger issues and no patience. He had a history of throwing items, slamming doors, and breaking his right hand after punching a chimney. The Veteran described leaving positions of employment due to the potential for conflict because he felt his ethics and expectations of other people were too high. This made it difficult for him to maintain consistent employment. He also indicated an inability to take on a leadership role like that of a foreman because he could not handle a position that dealt with conflict in the workplace. He reported intrusive thoughts related to ambushes in service, nightmares, avoidance behavior, loss of interest in things he once enjoyed, and feelings of detachment or estrangement from others. He denied current suicidal or homicidal ideation. W.A.'s mental status examination found he was easily engaged but appeared reticent to discuss is military experiences directly. His speech was soft and slow. His impulse control was below the normal limits. He reported a history of angry outbursts and substance abuse. He had a circumstantial thought process but his thought content with within normal limits. He reported an anxious mood and had a blunted affect. His concentration and memory were within normal limits. His judgment and insight were below normal limits. In February 2011 and February 2013, W.A. assessed the Veteran with a GAF score of 49 based on the presence of serious symptoms in social, occupational, or school functioning. This was based on the Veteran's description of social isolation and an extensive history of self-medication with alcohol, which interfered with his family relationships. Overall, W.A. opined that social functioning impairment and difficulty with impulse control (i.e., irritability and angry outbursts) would likely cause a substantially negative impact on his employability. His prognosis was guarded. The opinions of W.A. were found probative. These opinions were based on a review of the record and a clinical interview. Treatment notes from July 2010 to April 2012 found his sleep was variable. In May 2011, he reported feeling wired, tired, unable to relax, exhausted, and unable to sleep at the end of the day. In November 2011, he reported waking up at midnight. He sometimes could fall right back to sleep and other times was restless. He reported nightmares sometimes. By April 2012, he reported his sleep was improved. He was still waking up at midnight and having nightmares, but not as often. Generally, the Veteran's mental status examinations were normal except for a mildly dysphoric mood. He had a GAF score of 53 in April 2011 and February 2012. In a July 2013 VA examination for alcohol abuse/dependency, the Veteran reported marital tension. However, the relationship had improved when he stopped drinking. He indicated a good but distant relationship with his daughters. He was active with his VA therapy group but had no social support or friends. The Veteran reported difficulty sleeping, loss of interest and motivation, and irritability. He had a depressed mood, anxiety, suspiciousness, and panic attacks weekly or less often. The VA examiner opined to occupational and social impairment with reduced reliability and productivity. Additionally, he had a GAF score of 53. The July 2013 VA examination was probative evidence, as it relied on sufficient facts and data, and provided a rationale for the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Treatment notes in July 2013 noted intrusive thoughts, avoidance behavior, hyperarousal, and low motivation and energy. He reported restless sleep but a stable mood. His mental status examination was normal. He was casually groomed, oriented, cooperative, had coherent speech, a euthymic mood, calm affect, organized thought process, and denied delusions and paranoia. He was assessed with a GAF score of 55. In March 2014, the Veteran reported to doctors that he had nightmares once a week and was reading the Bible daily. His mental status examination was normal. He was dressed appropriately, had calm motor activity, normal speech, a euthymic mood, broad affect, normal concentration, normal memory, a linear thought process, good judgment, and good insight. Seven months later, he reported good sleep averaging eight hours a night and a stable mood. In December 2014, V.N., the Veteran's sister in law, opined she noticed similarities to her own husband, who had also served in Vietnam. The Veteran had nightmares, a short fuse, depression, and anger. The only correct way to do something was his way. He would snap at others for completing a task in a different way from him. V.N. believed her brother in law refused to admit the extent of his suffering in order to not look weak. In December 2014, R.N., the Veteran's brother in law, opined they only discussed family and work when they first met. The Veteran never wanted to talk about Vietnam. R.N., who also served in Vietnam, initially believed he did not deserve help and saw the same mentality from his brother in law. The Veteran told him he had not been sober since his separation from service. This was his way of coping, sleeping, and keeping his mind off things. According to R.N., the Veteran had no friends and was most comfortable with other veterans. In December 2014, L.G., the Veteran's wife, reported meeting her husband many years after his separation from service. He drank all the time and did not care if he lived or died. She described him as quiet. His family did not understand what he was going through because he did not talk about his experiences. L.G. opined he had a temper. His co-worker told her that he had spats of anger on the job. He would get upset with tools and throw them off the building. L.G. reported when he had to be foreman, he was so stressed that he lost 20 pounds. Close to the time he retired he went through jobs quickly. He would quit because he did not want to work anymore and then start looking for work again after an anxiety filled weekend. Eventually, he retired because he was laid off and there were no new jobs in sight. He watched little television and could not watch violent shows. He stopped reading novels and only read the Bible. He also had terrible nightmares. V.N., R.N., and L.G. are competent to report their observations and conversations with the Veteran. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). However, these opinions are not accorded greater probative weight than a qualified medical professional regarding a complex medical question. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). In November 2015, treatment records show the Veteran reporting five out of 10 depression and anxiety. He indicated watching the news upset him. He continued to report nightmares, however, he also reported getting eight hours of sleep. He had good energy, no concentration complaints, and no psychomotor retardation or agitation. The Veteran's mental status examination was normal. He was appropriately dressed, alert, and calm. His mood and affect were euthymic. He had normal concentration, memory, and thought process. There was no evidence of hallucinations. His judgement and insight were good. An August 2016 therapy progress assessment noted his heightened anxiety and anger continued. However, he continued to deny suicidal or homicidal ideation. In April 2017, he reported depression at a one to two out of 10 and no anxiety. He was sleeping an average of seven hours a night, had good energy, and no concentration complaints. The Veteran's mental status examination was normal. He was appropriately dressed, alert, and calm. His mood and affect were euthymic. He had normal concentration, memory, and thought process. There was no evidence of hallucinations. His judgement and insight were good. In July and September 2017, his therapy progress notes indicated some hyperarousal issues and a low tolerance to stressors. He denied suicidal or homicidal ideation. There was no evidence of decompensation, deterioration, or exacerbation of past conditions. His thoughts were clear, well organized, and relevant to the subject. By January 2018, he reported depression of four out of 10 and anxiety of two out of 10. He was getting seven to 10 hours of sleep but continued to report nightmares. He had good energy and denied suicidal or homicidal ideation. There was no evidence of decompensation. In a March 2018 VA examination for his PTSD, the Veteran denied any current significant problems with his marriage and contact with his daughters. He spent most of his time with other veterans. He had difficulty establishing friendships. He reported working as a union iron worker in New England from 1976 to 2005 when he retired. However, he started working again from 2006 to 2009 in Florida. He indicated ended his employment in 2009 because it affected his job pension and that he was not currently employed because he was too old. The Veteran reported symptoms including a depressed mood, anxiety, chronic sleep impairment, disturbance of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The March 2018 examiner observed appropriate grooming and appearance, relaxed motor activity, and an easy ability to establish a rapport. His speech was normal, concentration intact, and thought process linear. His mood was slightly depressed and affect restricted. He denied suicidal or homicidal ideation. The March 2018 examiner opined his condition caused occupational and social impairment with reduced reliability and productivity. The March 2018 VA examination was probative evidence, as it relied on sufficient facts and data, and provided a rationale for the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In February 2021, B.C. (MS, CRC) provided a private vocational assessment. The Veteran reported avoiding others, hypervigilance, intrusive thoughts, an exaggerated startle response, feeling detached from others, avoiding distressing thoughts and feelings related to his traumatic experiences, difficulty sustaining concentration and focus, irritability, angry outbursts, a depressed mood, poor sleep, and fatigue. He reported no socialization outside the home. He only left to grocery shop and attend VA appointments. He shopped early in the morning to avoid other people. B.C. opined it was more likely than not that he was unable to secure and follow substantially gainful employment because of his service-connected PTSD since at least April 2010 through the present. Non-exertional limitations due to PTSD impacted his pace and productivity as well as his ability to interact appropriately and effectively with others. It was more likely than not he was unable to work appropriately and effectively with co-workers, supervisors, and the public due to anger, irritability, and isolative tendencies associated with his service-connected PTSD. He would more than likely be unable to sustain concentration on work tasks for two consecutive hours and pace due to PTSD symptoms such as anxiety, depression, hypervigilance, intrusive thoughts and memories, and nightmares and poor sleep causing daytime fatigue. Finally, B.C. opined it was unlikely that the skills he acquired from past employment would transfer to sedentary work. The Board finds the opinion of B.C. less probative than those of the July 2013 and March 2018 VA examiners. B.C. opines the Veteran would more likely than not be unable to secure and follow substantially gainful employment because of his service-connected PTSD, which impacts his pace and productivity, ability to interact with others, and concentration. B.C. noted reviewing the Veteran's claims file in addition to conducting a phone interview. Treatment records from June 2010 to January 2018 noted the Veteran's reports of intrusive thoughts, avoidance behavior, hyperarousal, variable sleep, low motivation, heightened anxiety, and anger issues. However, his treating providers observed him to be alert, oriented, and cooperative. His memory and concentration were normal. His thought process was organized, and he denied delusions as well as suicidal or homicidal ideation. His judgment and insight ranged from fair to good. The Veteran's mood ranged from mildly dysphoric to euthymic. Having considered the credible lay reports and weighing the medical opinions of record, the Board resolves reasonable doubt in the Veteran's favor and finds the severity, frequency, and duration of the Veteran's symptoms more closely approximated occupational and social impairment with deficiencies in most areas. The Board acknowledges that the results of the VA examinations and the symptoms described in the mental health treatment notes do not indicate that the Veteran experiences all of the symptoms associated with a 70 percent disability rating for an acquired psychiatric disorder to include PTSD. However, the Court has held that the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, a finding that there are deficiencies in most areas is sufficient to warrant a 70 percent disability rating, even though all the specific symptoms listed for a 70 percent rating are not manifested. Thus, for all the foregoing reasons, the Board finds that an initial 70 percent rating for PTSD is warranted. After reviewing evidence of record as a whole, the Board finds that the assignment of a disability rating greater than 70 percent for the Veteran's PTSD is not warranted. While treatment records demonstrate that the Veteran experienced significant occupational and social impairment, the Board again notes that the maximum rating of 100 percent requires total occupational and social impairment. In not granting a 100 percent schedular rating for the Veteran's service-connected PTSD with alcohol abuse/dependency, the Board is not minimizing the severity of the Veteran's symptoms. The Board notes that the evidence demonstrates that the Veteran experienced significant social impairment as a result of his PTSD as he is socially withdrawn and has indicated that he has no friends. However, as noted above, the maximum rating of 100 percent requires total occupational and social impairment. The VA treatment records and VA examinations do not show gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting himself or others, disorientation to time or place, or memory loss for names of relatives, his occupation, or his own name. Additionally, there were no reports of homicidal ideation. Accordingly, in this case, the overall evidence of record does not reflect that the Veteran's symptomatology is so severe as to merit an initial 100 disability rating. 2. Entitlement to a TDIU is denied. Applicable Law and Regulations Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation because of service-connected disabilities, provided that the Veteran meets the schedular requirements. If there is only one service-connected disability, this disability should be rated at 60 percent or more; if there are two or more disabilities, at least one should be rated at 40 percent or more with sufficient additional service-connected disability to bring the combination to 70 percent or more. 38 C.F.R. § 4.16(a). To meet the requirement of "one 60 percent disability" or "one 40 percent disability," the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Substantially gainful employment is defined as work which is more than marginal, and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. If a Veteran fails to meet the threshold minimum percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director of Compensation and Pension Service for extraschedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation because of service-connected disability. 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, despite the Veteran not meeting the percentage requirements for a TDIU, the Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected conditions and advancing age which would have justified TDIU. 38 C.F.R. §§ 3.341(a), 4.19; see Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b) (2012). For the VA to deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App., at 54. Factual Background and Analysis The Veteran contends he has been unable to work because of his service-connected disabilities. The Veteran has been unemployed since 2009 and the criteria for TDIU under 38 C.F.R. § 4.16(a) are met through the grant of a 70 percent disability rating for PTSD above. In June 2013 and December 2020, the Veteran provided a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. He reported completing high school. He indicated receiving no other education or training since becoming too disabled to work in November 2009. He had a career as a union iron worker following his separation from service until November 2009. He noted work helped to distract him from intrusive thoughts of combat because it required intense focus. He also liked that it was a solitary job and consistently refused foreman work because of the stress of interacting with others. The Veteran reported retiring in 2005 but without the preoccupation of work he developed a drinking problem. He returned to work and eventually retired in 2009. The Veteran indicated a history of periods of short-term employment with several employers since 2005. He left several jobs due to frustration and would find new positions through the union. He reported daily intrusive thoughts of his time in service, pacing the house checking doors and windows, difficulty focusing, sleeping only four to six hours a night, restless sleep, and nightmares several times a week. He does not like public places because he always feels under threat, therefore, he isolates himself. He struggles to interact with strangers and communicate with non-veterans. His relationship with his daughters is distant. The Veteran is competent to report on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to describe his symptoms and their effect on his daily activities. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). In August 2014, URS Energy and Construction Inc., provided a VA Form 21-4192. The Veteran was employed from September 4, 2007 to December 8, 2007. He worked 40 hours a week as an ironworker. His employment ended because he was laid off. In October 2014, International Association of Bridge, Structural, Ornamental Iron Workers of America (Local 808) provided a VA Form 21-4192. The Veteran was employed form January 5, 2009 to October 28, 2009. He worked 60 hours a week as a welder. His employment ended when he retired. The December 2010 VA examiner opined the Veteran had chronic moderate PTSD symptoms, which would cause clinically significant functional impairment. The examiner also opined he had transient or mild symptoms causing decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner's assessment provides conflicting findings as to the severity of the Veteran's condition. Therefore, the December 2010 opinion was accorded little probative weight. W.A. (Psy.D.) provided private psychological evaluations of the Veteran in February 2011 and February 2013. W.A. assessed the Veteran with a GAF score of 49 based on the presence of serious symptoms in social, occupational, or school functioning. This was based on the Veteran's description of social isolation and an extensive history of self-medication with alcohol, which interfered with his family relationships. He reported completing high school and an iron worker's apprenticeship. He was accepted into the International Association of Bridge, Structural, and Ornamental Ironwork. The Veteran described leaving jobs because of the potential for conflict. His ethics and expectations of other people were too high. During the interview he was easily engaged but appeared reticent to discuss his military experience. His impulse control was noted to be below normal limits by his reported history of angry outbursts and substance abuse. His thought process was found circumstantial, but his concentration and memory were within normal limits. His insight and judgment were below normal limits. Overall, W.A. opined that social functioning impairment and difficulty with impulse control (i.e., irritability and angry outbursts) would likely cause a substantially negative impact on his employability. His prognosis was guarded. The opinions of W.A. were accorded positive probative weight. The Board notes W.A.'s opinion that the Veteran's employability would be negatively impacted by impairment in his social functioning and difficulty with impulse control. However, W.A. does not find the Veteran incapable of performing substantially gainful employment. In December 2014, V.N., the Veteran's sister in law, opined the Veteran had nightmares, a short fuse, depression, and anger. The only correct way to do something was his way. He would snap at others for completing a task in a different way from him. V.N. believed her brother in law refused to admit the extent of his suffering in order to not look weak. In December 2014, R.N., the Veteran's brother in law, opined the Veteran told him he had not been sober since his separation from service. This was his way of coping, sleeping, and keeping his mind off things. The Veteran had no friends and was most comfortable with other veterans. In December 2014, L.G., the Veteran's wife, reported he drank all the time and did not care if he lived or died. She described him as quiet. His family did not understand what he was going through because he did not talk about his experiences. L.G. opined he had a temper. His co-worker told her that he had spats of anger on the job. He would get upset with tools and throw them off the building. L.G. reported her husband lost 20 pounds when he had to be foreman at work due to the stress. Close to the time he retired he went through jobs quickly. He would quit because he did not want to work anymore and then start looking for work again after an anxiety filled weekend. Eventually, he retired because he was laid off and there were no new job prospects. He watched little television and could not watch violent shows. He stopped reading novels and only read the Bible. He also had terrible nightmares. V.N., R.N., and L.G. are competent to report their observations and conversations with the Veteran. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). However, these opinions are not accorded greater probative weight than a qualified medical professional regarding a complex medical question. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). In a July 2013 VA examination for alcohol abuse/dependency, the Veteran reported marital tension. However, the relationship had improved when he stopped drinking. He indicated a good but distant relationship with his daughters. He was active with his VA therapy group but had no social support or friends. The Veteran reported difficulty sleeping, loss of interest and motivation, and irritability. The examiner noted the following symptoms: a depressed mood, anxiety, suspiciousness, and panic attacks weekly or less often. The VA examiner opined to occupational and social impairment with reduced reliability and productivity. Additionally, he had a GAF score of 53. In a March 2018 VA examination for his PTSD, the Veteran denied any current significant problems with his marriage and contact with his daughters. He spent most of his time with other Veterans. He had difficulty establishing friendships. He reported working as a union iron worker in New England from 1976 to 2005 when he retired. However, he started working again from 2006 to 2009 in Florida. He indicated ended his employment in 2009 because it affected his job pension and that he was not currently employed because he was too old. The Veteran reported symptoms including a depressed mood, anxiety, chronic sleep impairment, disturbance of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The examiner observed the Veteran was appropriately groomed, had a relaxed motor activity, was cooperative, and easily established a rapport. His concentration appeared intact and his thought process was linear. He denied suicidal or homicidal ideation. His mood was slightly depressed and his affect restricted. The VA examiner opined his condition caused occupational and social impairment with reduced reliability and productivity. The July 2013 and March 2018 VA examiners had access to the claims file and were sufficiently informed of the relevant facts including the Veteran's lay statements so as to be able to form an appropriate medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, positive probative weight was given to these opinions. In February 2021, B.C. (MS, CRC) provided a private vocational assessment. B.C. opined it was more likely than not that he was unable to secure and follow substantially gainful employment because of his service-connected PTSD since at least April 2010 through the present. Non-exertional limitations due to PTSD impacted his pace and productivity as well as his ability to interact appropriately and effectively with others. It was more likely than not he was unable to work appropriately and effectively with co-workers, supervisors, and the public due to anger, irritability, and isolative tendencies associated with his service-connected PTSD. He would more than likely be unable to sustain concentration on work tasks for two consecutive hours and pace due to PTSD symptoms such as anxiety, depression, hypervigilance, intrusive thoughts and memories, and nightmares and poor sleep causing daytime fatigue. Finally, B.C. opined it was unlikely that the skills he acquired from past employment would transfer to sedentary work. The vocational expert noted use of the Dictionary of Occupational Titles (DOT), which is used extensively in State and Federal Courts as well as by the Social Security Administration (SSA). She reported being unaware of any other authoritative, vocationally based definition for the term "sedentary employment." The Board notes that VA regulations contain many factors to be considered as part of a TDIU analysis. See 38 C.F.R. §§ 4.16, 4.19. Whether a veteran can perform "sedentary work" or "sedentary employment" is not among them. In fact, neither the term nor any similar phrase is mentioned, much less defined, in any relevant VA statute or regulation. The Board must sufficiently explain how it interpreted the use of the term "sedentary" and how the concept of sedentary work figures into a veteran's overall disability picture and vocational history. Withers v. Wilkie, 30 Vet. App. 139 (2018). Withers declines to adopt a specific definition of the phrase "sedentary employment" for VA purposes when adjudicating entitlement to a TDIU, but instead holds, as noted above, that the Board must provide a definition on a case by case basis. Merriam-Webster online dictionary defines sedentary as doing or requiring much sitting, not physically active. See https://www.merriam-webster.com/dictionary/sedentary. Under 20 C.F.R. 404.1567(a), SSA defines sedentary work as work that involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one that involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met. The Board finds these definitions are persuasive for purposes of this claim, as the Department of Labor and SSA have expertise in and are charged with defining the exertional requirements of different jobs in the national economy, and SSA is charged with determining the capacity of an individual to satisfy those requirements in adjudicating disability claims. The Board finds the opinion of B.C. less probative than those of the July 2013 and March 2018 VA examiners. B.C. opines the Veteran would more likely than not be unable to secure and follow substantially gainful employment because of his service-connected PTSD, which impacts his pace and productivity, ability to interact with others, and concentration. B.C. noted reviewing the Veteran's claims file in addition to conducting a phone interview. Treatment records from June 2010 to January 2018 noted the Veteran's reports of intrusive thoughts, avoidance behavior, hyperarousal, variable sleep, low motivation, heightened anxiety, and anger issues. However, his mental status examinations were generally normal. He denied suicidal or homicidal ideation. He was appropriately dressed and had a neat appearance. He was alert, oriented, cooperative, and had normal speech. His memory and concentration were normal. His thought process was organized, and he denied delusions and hallucinations. His judgment and insight ranged from fair to good. His mood ranged from mildly dysphoric to euthymic. Accordingly, the Board finds the weight of the available evidence demonstrates that the criteria for a TDIU have not been met or more nearly approximated. While the medical and lay evidence indicates that the Veteran was limited in his functional capacity it does not show that his service-connected conditions prevented him from obtaining or maintaining substantially gainful employment. Therefore, the Board finds the evidence does not reflect that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.L. Byers 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.