Citation Nr: 21031046 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 17-15 076 DATE: May 20, 2021 ORDER 1. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder with alcohol abuse (PTSD) prior to May 27, 2015 is denied. 2. Entitlement to an initial disability rating in excess of 70 percent for PTSD from May 27, 2015 is denied. 3. Entitlement to referral for extraschedular consideration for a total disability rating for compensation based upon individual unemployability (TDIU) prior to May 27, 2015 is denied. 4. Entitlement to a TDIU rating from May 27, 2015 is denied. FINDINGS OF FACT 1. Prior to May 27, 2015, PTSD was not manifested by occupational and social impairment with reduced reliability and productivity. 2. From May 27, 2015, PTSD has not been manifested by total social and occupational impairment. 3. The preponderance of the evidence is against a finding that the Veteran has been unable to secure or follow a substantially gainful occupation by reason of service-connected disability during the appeal period. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating in excess of 30 percent for PTSD were not met prior to May 27, 2015. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.125, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for entitlement to an initial disability rating in excess of 70 percent for PTSD have not been met from May 27, 2015. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.125, 4.130, DC 9411. 3. The criteria for referral for an extraschedular TDIU rating were not met prior to May 27, 2015. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16(b). 4. The criteria for entitlement to a TDIU rating have not been met from May 27, 2015. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the Marine Corps from April 1965 to March 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal of a July 2015 rating decision that increased the Veterans disability rating for PTSD to 70 percent as of May 2015. In his appeal, the Veteran has alleged that the service-connected PTSD prevents him from being employed. As such, a claim for TDIU was added, subject to Rice v. Shinseki, 22 Vet. App. 447 (2009), which states that, whether expressly raised by a Veteran or reasonably raised by the record, a TDIU claim is part of the adjudication of a claim for increased compensation. The Veteran has an extended history of alcohol abuse and has reported additional symptoms of PTSD, including flashbacks, depression, anxiety, panic attacks, sleep difficulties, low motivation, irritability, memory and concentration deficits, social withdrawal, and isolation. He has stated that these problems preclude him from being able to gain or follow a substantially gainful occupation. Increased Ratings VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of 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 evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran's service-connected PTSD has been evaluated under 38 C.F.R. § 4.130 using the General Rating Formula for Mental Disorders, which assigns ratings based on particular symptoms and the resulting functional impairments. See 38 C.F.R. § 4.130, DC 9411. The General Rating Formula is as follows: A 30 percent rating is assigned for 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 conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. 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; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms associated with each rating in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list; rather, they serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the DCs. See id. VA must consider all symptoms of a veteran's disorder that affect his or her occupational and social impairment. See id. at 443. If the evidence demonstrates that a veteran has symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the DC, the appropriate, equivalent rating will be assigned. Id. In this regard, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and a veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126. Although VA considers the level of social impairment, it does not assign an evaluation based solely on social impairment. Id. VA must consider all of the Veteran's symptoms and resulting functional impairment as shown by the evidence in assigning the appropriate rating, and will not rely solely on the examiner's assessment of the level of disability at the moment of examination. See id. The Board notes that the Veteran was assigned a temporary evaluation of 100 percent for PTSD from November 17, 2016 through December 31, 2016, for a hospitalization in excess of 21 days. As this is the maximum schedular award possible, this period will not be considered for purposes of an increased rating. Otherwise, the Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against an initial evaluation in excess of 30 percent prior to May 27, 2015, and in excess of 70 percent thereafter. The reasons follow. Prior to May 27, 2015 The evidence of record indicates that the Veteran began seeking mental health treatment from VA around the time of submission of his claim for service connection for PTSD in September 2014. In October 2014, the Veteran reported symptoms of depression, low energy, irritability, and poor sleep, although he indicated he gets approximately six hours of sleep per night. He denied suicidal ideation or changes in his ability to concentrate. He was described as calm, cooperative, oriented, and appropriately attired. He was assessed with poor judgment, fair insight, a linear thought process, intact memory, and no perceptual abnormalities. He reported that he enjoys golfing with friends. The Veteran reported generally stable symptomology the following month. In December 2014, the Veteran again was described as alert and oriented with a normal thought process, intact memory, no suicidal ideation or perceptual abnormalities, and fair insight and judgment. The Veteran underwent a VA psychological examination later in the same month. The Veteran reported a long history of alcohol abuse with intermittent periods of sobriety. He indicated that he had been drinking heavily for the past 10 years; however, at that time, he reported being 40 days sober. He reported a remote history of involuntary hospitalization approximately eight years earlier due to suicidal threats made while intoxicated. Separate records indicate that this incident occurred in 2010. He stated that he remained sober for approximately one year following his hospitalization. The Veteran reported that he and his wife had established a good social support group and that he engages in community activities, such as a model sailboat club. The Veteran was described as cooperative and agreeable. He was able to express himself in a coherent manner and denied suicidal ideation. There was no indication of impairment in basic cognitive functioning, including reasoning, judgment, recall, or communication ability. The Veteran reported that he has a good working relationship with his treating psychiatrist and with his substance abuse counselor. The examiner assessed the Veteran's level of impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran exhibited stable functioning into 2015 with predominantly normal findings on mental status examination. He reported continued depressive symptoms and flashbacks, but denied suicidal ideation and hallucinations and was described as calm and cooperative. He was repeatedly noted to be fully oriented with fair insight and judgment, a linear thought process, and intact memory. He was able to travel to Jamaica for vacation. A letter from the Veteran's readjustment counseling therapist Delia Chariker, MA, dated in January 2015 and received in May 2015, detailed the Veteran's symptoms of persistent anxiety, chronic sleep impairment, persistent flashbacks, irritability, blunted affect, impairment in thought process and communication, inability to establish and maintain effective relationships. She stated that the Veteran has not made sustained improvement and has deteriorated socially. However, the therapist's statement seems to solely reflect the Veteran's own reports of his functioning, which is at odds with the evidence of record during the relevant period, and does not contain a concurrent mental status examination. For example, the letter states that the Veteran was hospitalized for a suicide attempt in the previous year. However, there is no evidence of this occurrence in the Veteran's medical treatment records. Rather, the Veteran has reported that he was hospitalized on one occasion for making suicidal threats while intoxicated prior to the relevant period approximately between 2006 and 2010. Additionally, the evidence shows that the Veteran has been married to this second wife since approximately 2005. At the December 2014 VA examination, the Veteran reported that he and his wife live in an over-55 community, and he felt that "they have established a good social support group," which refutes Ms. Chariker's conclusion that the Veteran is unable to establish and maintain effective relationships. The U.S. Court of Appeals for Veterans Claims has held that opinions based on inaccurate factual premises are not entitled to probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Despite the Veteran's symptoms of PTSD and alcohol abuse, the Veteran maintained his activities of daily living with intact cognitive functioning and appropriate social engagement and behavior. There were no exacerbations during the prescribed period that warranted emergency or inpatient care and the Veteran regularly denied suicidal ideation. Additionally, as discussed below, the Veteran's routine treatment records generally rebut many of the therapist's conclusions, including that the Veteran's disability is characterized by impairment in thought process or communication. The evidence of record prior to May 27, 2015 is largely absent of the symptoms listed in the schedular criteria for a 50 percent disability or symptoms of similar severity and frequency, which includes 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The Veteran was assessed with poor judgment on one occasion in October 2014, but was found to have fair judgment on recurrent mental status examinations thereafter. Additionally, the Veteran was routinely found to have intact cognitive functioning with no impairment in reasoning, memory, or communication. He reported low energy/motivation, but he maintained independence in activities of daily living, reported community engagement, and reported an extended period of sobriety. As to his ability to establish and maintain relationships, the Veteran lived with his wife during this period and reported enjoying golfing with friends and engaging in community activities, such as model shipbuilding. He also reported good working relationships with his treating providers. He was assessed as calm and cooperative with a congruent affect. Such findings do not support the award of an increased rating in excess of 30 percent prior to May 27, 2015. Rather, it appears that the Veteran's primary symptoms of depression, flashbacks, irritability, low motivation, and sleep disturbances are more closely approximated by the schedular criteria for a 30 percent disability rating, which specifically considers depressive and anxious symptoms, as well as chronic sleep impairment. The Board acknowledges the treatment records showing a remote hospitalization for suicidal threats while intoxicated in approximately 2010. However, the facts of this case are distinguishable from those described in Bankhead v. Shulkin, 29 Vet. App. 10 (2017), in which the Court held that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas (a 70 percent disability rating under 38 C.F.R. § 4.130). Under the facts of Bankhead, the claimant was noted to have had recurrent suicidal thoughts and behaviors of varying severity, frequency, and duration throughout the relevant appeal period. The Veteran's history of inpatient hospitalization is not reflected in the level of occupational and social impairment contemplated by the 70 percent disability rating during the relevant period. Here, the Veteran, on VA examination, endorsed occasionally feeling as though "there's not a lot keeping me here," but denied suicidal ideation at the time and has generally denied any suicidal plan or intent. Despite the Veteran's remote history of hospitalization, there has been no such episodes requiring inpatient or urgent treatment during the relevant period. The Veteran routinely denied suicidal ideation and was found to be a low risk of harm to himself and others. He maintained intact cognitive functioning and independence in his activities of daily living. The Veteran's overall disability picture does not rise to the level of occupational and social impairment with reduced reliability and productivity due to such symptoms or deficiencies in most areas during this part of the appeal period. From May 27, 2015 The day after the effective date of the award of a 70 percent disability rating, the Veteran presented for VA treatment and reported that he was depressed all the time. Findings on mental status examination remained consistent with those described above in early 2015. The Veteran underwent a VA examination in July 2015. The Veteran was cooperative and articulate. He had a friendly demeanor, which eventually changed to a flattened affect with periods of tearfulness. He reported drinking actively and excessively. The examiner indicated two changes since the time of the Veteran's December 2014 VA examination. The first was that the Veteran and his wife were on "a break" and that she had not been living with him for the past month. The second change was that he reported increased social isolation, only leaving the house for appointments, necessary errands, and the liquor store. The examiner characterized the Veteran's disability as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. In September 2015, the Veteran reported worsening psychosocial stressors, relating primarily to legal issues that his wife was involved in, causing financial difficulties and social tension with his neighbors. He and his wife were together again, pursuing a move to the Myrtle Beach area. He continued to report depression, anhedonia, sleep difficulties, low energy, and social isolation, but he denied suicidal ideation and was assessed as calm and cooperative with intact memory, adequate attention and concentration, fair insight and judgment, and a linear thought process with intact cognitive functioning. The record shows generally stable functioning thereafter. In late 2015, the Veteran reported that he had a new home in North Carolina being built, his sleep was improved with medication, and his relationship with his wife had been going surprisingly well. In early 2016, the Veteran was again able to travel outside the country for vacation. In an April 2016 statement, the Veteran stated that his PTSD symptoms prevent him from maintaining full-time employment, causing flashbacks, poor memory, diminished ability to learn, social isolation, and verbal altercations with a former employer. The Veteran continued to struggle with reducing his alcohol consumption thereafter and expressed interest in additional options for establishing and maintaining abstinence. The Veteran entered a 40-day inpatient alcohol treatment program through VA in November 2016, during which time he received a temporary 100 percent disability rating. During treatment, the Veteran actively participated in group therapy and was described as respectful. He also expressed an interest in performing volunteer work. After discharge, the Veteran reported remaining sober in January and February 2017. He stated he was keeping busy by exercising, taking piano lessons, and golfing with his wife. He reported trying to keep his hours full because he knows that he does not do well when bored. He also reported that his sleep was "reasonably good." He reported some increased irritability in sobriety but was described as cooperative, maintained intact cognitive functioning on mental status examination, and denied suicidal ideation. In April 2017, the Veteran submitted a statement indicating that he has trouble concentrating, difficulty being around others, and experiences flashbacks, sleep deprivation, irritability, exhaustion, low motivation, paranoia, hypervigilance, and periodic panic attacks. He stated that his irritability has escalated to violence in the past, including an incident involving violence "a few years ago" in which the Veteran got "locked up for a while." He stated that he no longer enjoys prior activities such as remote-controlled shipbuilding and that he goes extended periods ignoring his hygiene. He stated that he has no friends and no family with whom he likes to associate. He stated that he cannot work with others and is not disciplined enough to work alone. His wife also submitted a statement echoing the Veteran's reported symptomology. However, during treatment in the same month, the Veteran was neatly groomed with good hygiene. He was described as cooperative and fully alert and oriented. He denied suicidal ideation and was found to have a logical, coherent, thought process, fair insight and judgment, intact memory, and adequate attention and concentration. In May 2017, the Veteran reported six months of sobriety, and he denied depressive symptoms. He stated that his mood was "not great" but improved from when he was drinking. The Veteran's findings on mental status examination remained relatively consistent thereafter. The Veteran underwent a vocational assessment by private vocational consultant Brenda Martinez Richardson, MS, CRC, PVE, in August 2017 based on a review of the record and a telephone interview with the Veteran. The consultant provided the Veteran's vocational history, as well as a summary of the Veteran's treatment record. The consultant also reported the Veteran's stated symptoms, to include reduced concentration, social isolation, sleep difficulty, flashbacks, low motivation, irritability, and paranoia. The consultant stated that the mental limitations established in the Veteran's December 2014 VA examination denote service-connected disability that prevent him from securing or maintaining gainful employment at any exertional or skill level. The consultant stated that separate medical records indicate no subsequent improvement thereafter. The consultant stated that the Veteran has no transferable skills from past work to jobs that can be performed within the limitations specified by the medical records. She further added that the Veteran was unable to secure or follow a substantially gainful occupation since 2013 when he could no longer tolerate performing any type of work activity, even that of a part-time parking attendant. The Board finds the assessment of the private vocational consultant to be of limited probative value because its conclusions are not supported by the overall evidence of record. For example, the consultant stated that the December 2014 VA examination denotes disabilities that prevent the Veteran from securing or maintaining gainful employment at any exertional level or skill level. The consultant did not explain how that is the case and the assessment of the December 2014 VA examiner indicated the Veteran's level of impairment to be commensurate with a 30 percent disability rating, which expressly rebuts the assertion that the Veteran was unable to secure or maintain gainful employment due to his service-connected disability. The consultant also stated that the Veteran has been unable to tolerate performing any type of work activity since he last worked in 2013 without specifically addressing why the Veteran was unable to work at that time. The consultant stated that an analysis showed that the Veteran had no skills that would transfer from past work to jobs "that can be performed within the limitations specified by the medical records," but does not explain the limitations specified by the medical records. Rather, it seems that the consultant was overly reliant on self-reporting and overlooked evidence that demonstrates higher levels of overall functioning. The consultant stated that the Veteran has not experienced improvement but neglects to mention references in the record to improved functioning during periods of sustained sobriety, which the Veteran has successfully maintained. These inconsistencies lessen the probative value of the vocational consultant's conclusions. While the Veteran is competent to report his observed symptoms, his reported symptoms during recurrent VA treatment have often been less severe than those reflected in submitted statements or reported to examiners and third parties. For example, the Veteran has reported low energy, as well as memory and concentration deficits, but has routinely been found to have intact cognitive functioning, including being fully alert and oriented with intact memory and adequate attention and concentration. Despite his irritability and reported history of violence, the record does not document any episodes of violence during the relevant period, and he was routinely described as calm and cooperative with appropriate behavior, even during periods of regular drinking. The vocational consultant also described the Veteran as polite. The Veteran reported that he has lost interest in his personal hygiene, but was routinely described as well groomed, and he has maintained independence in his activities of daily living. He has reported social isolation and withdrawal, but has traveled out of the country for vacation multiple times, and has reported golfing with his wife and friends, going to a wedding, attending recovery meetings, and taking piano lessons. The Board finds the recurrent examination findings noted throughout the treatment records to be more probative than lay statements, as they are concurrently recorded by medical professionals with expertise on psychological disorders and reflect the Veteran's functioning at the time of examination, rather than recollections of symptoms from months or years prior. The totality of the evidence largely contradicts the level of impairment described by the private vocational consultant. Furthermore, the evidence of record does not demonstrate the Veteran to have total and social occupational impairment, as needed to warrant an increased rating of 100 percent. As noted, the Veteran has maintained his marriage of more than a decade, despite a brief "break." The Veteran reported golfing with his wife after his discharge from his late-2016 hospitalization. They have stayed together and built a new home in recent years. He stated that, despite legal troubles, their relationship was going surprisingly well. These findings are evidence against total social impairment. Additionally, the Veteran's demonstrated ability to sustain sobriety for long periods with intact cognitive functioning does not support a finding of total occupational impairment. A 100 percent rating requires both total social and total occupational impairment, which the Board finds the preponderance of the evidence is against that level of impairment. Thus, an award of 100 percent disability rating for PTSD with alcohol abuse disorder is not warranted during this part of the appeal period. For all the reasons stated herein, the preponderance of the evidence is against an evaluation in excess of 70 percent from May 27, 2015, and in excess of 30 percent prior to that time. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. TDIU 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 disability or disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, the disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and enough additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). As a preliminary matter, the Veteran's service-connected disability does not meet the percentage requirements for a schedular TDIU under 38 C.F.R. § 4.16(a) prior to May 27, 2015. The Veteran is service-connected for PTSD with alcohol abuse disorder, which is 30 percent disabling from September 30, 2014, 70 percent disabling from May 27, 2015, 100 percent disabling from November 17, 2016, through December 31, 2016, and 70 percent disabling from January 1, 2017). Thus, the Veteran has a disability rating of 30 percent prior to May 27, 2015, and a 70 percent disability rating thereafter, except for a temporary 100 percent disability rating from November 17, 2016 to December 31, 2016. When the percentage requirements are not met, entitlement to a TDIU rating may be considered on an extraschedular basis when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability or disabilities. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular TDIU rating in the first instance. See Bowling v. Principi, 15 Vet. App. 1 (2001). However, it may determine whether the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability, and then refer the issue to the Director of the Compensation Service, for a determination in the first instance as to whether the Veteran is entitled to a TDIU rating on an extraschedular basis under 38 C.F.R. § 4.16(b). Accordingly, the Board will analyze whether the evidence of record demonstrates the need for a referral to the Director of the Compensation Service for extraschedular consideration prior to May 27, 2015. Additionally, the issue of entitlement to a TDIU rating is moot during the Veteran's temporary 100 percent (total) disability rating from November to December 2016 and, therefore, will not be considered herein. The Board notes that a grant of a 100 percent schedular rating does not necessarily render the issue of entitlement to a TDIU rating moot, as a TDIU rating could, in certain circumstances, render the Veteran eligible for special monthly compensation (SMC). SMC may be warranted if the Veteran has a 100 percent disabling rating for a single disability, and VA finds that a TDIU rating is warranted based solely on disabilities other than the disability that is rated at 100 percent. See Buie v. Shinseki, 24 Vet. App. 242 (2011); Bradley v. Peake, 22 Vet. App. 280 (2008). However, the Board notes that the Veteran is service-connected for PTSD with alcohol abuse disorder only, and there is no separate service-connected disability which could potentially render the Veteran unemployable. Hence, the Board finds as fact that entitlement to a TDIU rating is moot for the period from November 17, 2016 to December 31, 2016. "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16. In determining whether a veteran can secure and follow a substantially gainful occupation, the Court in Ray v. Wilkie directed the Board to consider the following factors: (1) the veteran's history, education, skill, and training; (2) whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities required by the occupation at issue; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue. 31 Vet. App. 58, 73 (2019). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The responsibility for making the ultimate TDIU determination is placed on the adjudicator and not a medical examiner. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). A medical examiner's role is limited to describing the effects of disability upon the person's ordinary activity. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran is competent to testify as to facts he personally observed or described; this includes recalling what he personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). For purposes of TDIU consideration, the above analysis of the Veteran's increased rating claims for PTSD is incorporated herein. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against a finding that a TDIU rating or referral for extraschedular consideration of a TDIU rating is warranted. The reasons follow. Determinations regarding employability are an issue reserved to the adjudicator based on a totality of the evidence and not on any one particular opinion or examination. However, as discussed above, the August 2017 private vocational assessment is of reduced probative because it is poorly supported and inconsistent with the longitudinal evidence of record. Neither VA examiner has found the Veteran's psychiatric disorder to render the Veteran unemployable and treatment records generally reflect improved symptoms over time, as the Veteran was able to sustain sobriety following his 2016 inpatient treatment. Evidence of the Veteran's overall functioning does not reflect that he has been unable to gain or maintain substantially gainful employment due to his service-connected disability at any point during the relevant period. While the Veteran experiences a range of symptoms associated with PTSD with alcohol use disorder, as discussed above, they have not caused significant functional limitations that would preclude the Veteran from work. Recurrent mental status examination findings show that the Veteran has predominantly presented as fully alert and oriented, calm, cooperative, and well groomed, with a linear, goal-directed thought process, intact cognition and memory, adequate attention and concentration, intact judgment and insight, and no suicidal ideation. He has maintained his marriage of more than a decade, has maintained independence in activities of daily living, and has reported a wide array of activities, including international travel, golfing with friends and his wife, attending recovery meetings, driving, and taking piano lessons. Regarding the Veteran's education, training, skill, and work history, the Veteran reported that he has a GED and took some college classes, but never completed a college degree. VA educational documents show that the Veteran sought a associates degree followed by bachelor's degree in business administration, which included taking classes at Quincy Junior College. The Veteran reported that he worked for Verizon as an electrician for 38 years before accepting a buyout and retiring in 2009. He further reported working part time as a valet/parking lot attendant for approximately 10 months until April 2013. The Veteran reported that he left this employment due to PTSD symptoms. A statement from the former employer documents that the Veteran worked there for one year, where he worked 6 hours a day and 30 hours a week. The employer does not indicate that the Veteran was terminated or that he was provided any concessions relating to his disability. The Veteran's consistent employment history reflects that he is dependable and has a capacity for learning, training, and adaptation. These skills do not appear to have been hindered by the Veteran's service-connected disability, as he has been able to take on new challenges, such as piano lessons. These attributes would facilitate the Veteran's return to substantially gainful employment that the Veteran is capable of performing. As to the Veteran's physical capabilities, the Veteran is not service connected for any physical disability. While the effects of active alcohol abuse could potentially limit the Veteran's ability to perform certain physical tasks, the Veteran has demonstrated the ability to maintain sobriety for extended periods, and the record does not demonstrate sustained physical limitations relating thereto. In early 2017, the Veteran was filling his time with exercise. The Veteran has maintained independence in his activities of daily living and has maintained the ability to drive, play golf, and travel. Accordingly, the evidence supports a finding that the Veteran is physically capable of performing substantially gainful employment. As to the Veteran's mental capabilities, the record indicates him to be capable of performing substantially gainful employment. Despite recurrent symptoms of depression, irritability, anxiety, flashbacks, reported social isolation, low motivation and energy, and sleep difficulties, the Veteran has routinely recorded normal findings on mental status examinations and his overall functioning is improved during periods of sobriety with better sleep and improved mood. Recurrent examination findings show the Veteran to generally be fully alert and oriented, calm, cooperative, and well-groomed, with a linear, goal-directed thought process, intact cognition and memory, adequate attention and concentration, intact judgment and insight, and no suicidal ideation. The Veteran has routinely exhibited appropriate behavior and social skills. Accordingly, it appears that the Veteran's PTSD with alcohol use disorder can be accommodated by restricting the Veteran from work that requires frequent social interaction with the general public, and from occupations that require executive decision-making or supervisory/managerial duties. As such, the weight of the evidence shows that the Veteran is mentally capable of performing substantially gainful employment. Based on the above assessment of the Veteran's physical and mental abilities with consideration of his education, training, skills, and work history, the Board finds that the Veteran is capable of work that would result in income at the level of substantially gainful employment. For example, the Veteran's service-connected PTSD would not preclude the Veteran from occupations such as a warehouse worker, assembly line worker, or custodian, which are positions that would involve repetitive tasks without significant social interaction, such as a packer and sorter at an Amazon or some other warehouse. These are jobs that use everyday skills of lifting, cleaning, and organizing and do not require past experience in order to perform such duties or managerial or supervisory duties. These examples are not exhaustive but are merely illustrative of potential occupations that the Veteran could perform. This is evidence against a finding that the Veteran is unable to secure or follow all forms of substantially gainful employment due to his service-connected disability. For all the reasons described above, the Board finds that the preponderance of the evidence is against a finding that the Veteran is precluded from all forms of substantially gainful employment due to the service-connected PTSD and, therefore, is not entitled to a TDIU rating or a referral for consideration of an extraschedular TDIU rating throughout the appeal period. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, entitlement to a TDIU rating or a referral for consideration of a TDIU rating on an extraschedular basis is not warranted. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Wonderling, 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.