Citation Nr: 21040547 Decision Date: 07/05/21 Archive Date: 07/05/21 DOCKET NO. 20-16 463 DATE: July 5, 2021 ORDER Prior to December 19, 2019, entitlement to a 70 percent rating, but no higher, for posttraumatic stress disorder (PTSD), claimed as PTSD, OCD, anxiety, and insomnia due to nervous ticking, is granted. Entitlement to service connection for a total disability rating based on individual unemployability (TDIU) is denied. FINDING OF FACT 1. Prior to December 19, 2019, PTSD was manifested by symptoms causing occupational and social impairment with deficiencies in most areas but not by symptoms causing total occupational and social impairment. 2. The Veteran's service-connected disabilities did not preclude him from securing or following substantially gainful employment prior to December 19, 2019. CONCLUSION OF LAW 1. Prior to December 18, 2019, the criteria for a rating of 70 percent, but no higher, are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to TDIU have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 2013 to March 2017. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2018 rating decision by a Department of Veteran's Affairs (VA) Regional Office (RO) that granted service connection for "PTSD, previously claimed as PTSD, OCD, anxiety, and insomnia due to nervous ticking" and assigned an initial 50 percent rating effective March 12, 2017. The Veteran timely appealed the initial evaluation and requested a Board hearing, but later withdrew the hearing request. See VA Form 9; September 2020 statement in support of claim. An August 2020 rating decision granted a higher staged 100 percent disability rating, as well as special monthly compensation (SMC) at the housebound rate under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i), both effective December 19, 2019. As this is the highest rating allowed under Diagnostic Code (DC) 9411 and SMC is in effect, the Veteran has received a total grant of benefits sought on appeal for this issue from December 19, 2019 forward. The appeal period remaining before the Board is from March 12, 2017 to December 18, 2019. Increased Rating PTSD is evaluated pursuant to the General Rating Formula for Mental Disorders. A rating of 70 percent is assigned where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent evaluation is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Veteran has been diagnosed with other psychiatric disabilities during the appeal period. The U.S. Court of Appeals for Veterans Claims (Court) in Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), stated that "when it is not possible to separate the effects of the [service-connected condition and the non-service-connected condition], VA regulations at 38 C.F.R. § 3.102, which require that reasonable doubt on any issue be resolved in the appellant's favor, clearly dictate that such signs and symptoms be attributed to the service-connected condition. 61 Fed. Reg. 52698 (Oct. 8, 1996)." Thus, the psychiatric symptoms for other diagnoses will be attributed to the PTSD unless a medical professional has attributed them to another diagnosis. When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38U.S.C. §5107; 38C.F.R. §3.102. A claimant need only demonstrate an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For a claim to be denied on the merits, a preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Entitlement to a 70 percent rating for PTSD prior to December 18, 2019. The Veteran asserts that the rating for his service-connected PTSD from March 12, 2017 to December 18, 2019 did not accurately reflect the severity of his mental health symptoms. The Board agrees and grants a 70 percent disability rating for the entire appeal period from March 12, 2017 to December 18, 2019. However, the Board finds that for the period prior to December 18, 2019, a rating of 100 percent is not warranted, as the evidence does not show total social and occupational impairment prior to December 19, 2019. The Veteran's VA outpatient records show that the Veteran began seeking treatment for his mental health conditions in about June 2017, two months prior to the filing of his entitlement to service connection claim. In June 2017 the Veteran reported experiencing "difficulty falling and staying asleep, flashbacks, repetitive behavior, irritability, anger, constant hypervigilance, depression, loss of interest, low energy, poor self-esteem, poor appetite, poor concentration, restlessness, nightmares about 3 times per week, intrusive thoughts, avoidance, physical reactions (such as ticks), feeling cut off from others, intentionally isolating himself, being easily startled, and jumpy." The Veteran was also experiencing significant compulsions regarding the security of his home. The Veteran further stated that these symptoms make it "extremely difficult to do his work, take care of things at home, and get along with others." The Veteran was not employed at this time and stated he was having difficulty during job interviews because he was "too anxious and angry." He reports being in a constant state of worry. The Veteran was diagnosed with obsessive compulsive disorder (OCD) and PTSD at this time. In a July 2017 psychiatric initial note, the Veteran reported having significant compulsions to check his home for safety risks prior to leaving. The Veteran spent about 30 to 40 minutes checking his home before he could leave. Failure to complete these rituals would cause the Veteran to experience significant anxiety. At this time the Veteran was prescribed Paroxetine before being switched to Fluoxetine to help control his symptoms. The Veteran underwent a VA examination in October 2017 in which the examiner stated the Veteran was experiencing, "distressing memories and dreams, dissociate reactions, avoidance of or efforts to avoid external reminders that arouse memories, thoughts, or feelings associated with his experienced traumatic event, diminished interest or participation in significant activities, feelings of detachment or estrangement from others, irritable behavior, and sleep disturbance." The examiner also stated that, "features of this condition have included some social withdrawal, anxiety, worry, obsessive-compulsive issues, and depressive symptoms such as feelings of worthlessness." However, the examiner then noted a strong relationship between the Veteran and his family, to include his wife of just over one year despite stating he tended to self-isolate. The Veteran also reported quitting his position in management at a fitness company and instead taking a scheduling position with a dental company. The Veteran denied suicidal ideations at this time. The October 2017 VA examiner concluded that the Veteran had 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. However, despite endorsing only occasional occupational and social issues the examiner then goes on to state that the Veteran has occasional difficulty responding to demands, adapting to change, managing his own mental health symptoms, determining what is acceptable versus unacceptable work performance, and maintaining personal hygiene and attire appropriate for a work setting. The Veteran also experiences difficulty in cooperating with others, handling conflict, stating his own point of view, beginning and maintaining conversations, and understanding social cues. In February 2021 the Veteran submitted three letters from separate medical professions detailing the effects of the Veteran's medication on his PTSD and OCD symptoms. In summary, the letters confirm the Veteran's additional diagnosis of OCD and assert that due to the medication the Veteran was prescribed at the time of the October 2017 VA examination, his actual symptoms may not have been as apparent. However, the symptoms described and considered by the October 2017 VA examiner are consistent with the symptoms the Veteran reported during his VA outpatient mental health appointments both prior to and after the VA examination. Generally, VA does not consider the ameliorative effects of medication where such effects are not explicitly contemplated by the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56 (2012). However, DC 9411 expressly authorizes VA to take into account the ameliorative effects of medication when evaluating PTSD and other psychiatric disabilities. 38 C.F.R. § 4.130 DC 9411 (providing a noncompensable PTSD evaluation when, inter alia, "symptoms are not severe enough ... to require continuous medication" and a 10 percent PTSD evaluation when, inter alia, "symptoms [are] controlled by continuous medication"). As such, the Board finds that when rating psychiatric disabilities utilizing the General Rating Formula for Mental Disorders, the symptoms of a mental disorder are to be considered with the ameliorative effects of medication included. From September 2017 to the beginning of November 2017 the Veteran reported working for a dental company. At this time the Veteran was experiencing no suicidal ideations, lack of judgment, or lack of insight. Yet, the Veteran expressed he was living in a state of constant worry that something would go wrong. He expressed worry that something bad may happen to his family or they would get extremely sick or a household item would start a fire in his home. He also expressed feelings of being consumed by his obsession with need for exactness or symmetry and intrusive memories of his trauma. The Veteran also stated that he never tells people about how he is actually feeling and has a hard time expressing the extent of his mental health conditions because he does not want to "burden others." This leads to the Veteran withholding information about his mental health from his family and wife. The Veteran's VA outpatient mental health records from November 2017 to January 2018 also show his PTSD and OCD symptoms significantly affecting his day to day life. Again, the Veteran consistently denied suicidal ideations and stated he was still employed with the dental company. The Veteran reported feeling easily frustrated with his parents and not wanting to socialize with anyone including those he considered friends. While the Veteran stated he was "close" with his family he also stated that none of them know the extent to which his mental health interferes with his life. He again states that he internalizes his issues to not "burden" those around him. He further states more frustration at his family for making comments that downplay the seriousness of the Veteran's mental health conditions. In reference to employment, the Veteran stated that while he has had opportunities to do jobs that reflect his level of training and skill, he instead actively avoids taking those positions. He stated this was due to the "stress after the Coast Guard." The Veteran also continually described periods of emotional numbness and actively avoids thinking about his feelings. He began discussing the content of his intrusive thoughts with his therapist. For example, while away from home, the Veteran had extreme intrusive thoughts regarding the safety of his dog while boarded at the kennel. The Veteran stated that he does not typically discuss his intrusive thoughts but can open up to only his wife on occasion. The Veteran also reported having a difficult time recalling what had happened during the week to discuss in therapy. The Veteran reports being unable to discuss anything bad happening to member of his family without experiencing extreme emotional distress. He is unable to discuss any emotions regarding the traumatic incidents he experienced in service. He reports having nightmares but not wanting to tell anyone about them to avoid being a "burden." From January 2018 to March 2018, the Veteran reports similar symptoms as described above. The Veteran reports living in a constant state of anxiety and reports having panic attacks. While the Veteran reported having panic attacks regularly, he also reports actively avoiding his feelings and emotions. The Veteran described some of his intrusive thoughts to include graphic imagery of his wife dying. The Veteran stated that he has "intrusive thoughts and obsessions about killing his wife." These thoughts are reoccurring despite the self-reported good relationship the Veteran has with his wife. The Veteran also discusses the pressure of his wife stating he "cured her depression." However, the Veteran consistently denied suicidal and homicidal ideations. In February 2018 the Veteran stated his father went into the hospital which put him in a great amount of anxiety. He also stated that while he is still employed, he struggles with the responsibilities tasked to him at work. The Veteran again stated that he does not want to be a "burden" on others and feels like discussing his mental health, even in seeking support, is too much for those around him. He continued to deny suicidal and homicidal ideations. In April 2018 the Veteran reported that he saw a medical bag that reminded him of the traumatic events from service. This sent the Veteran into a state of extreme anxiety for which he required "self-[medicating]" to calm him. The Veteran stated that his wife offered support but then stated that he does not discuss his mental health issues with anyone outside of therapy. He denied suicidal and homicidal ideations. From January 2019 to June 2019, the Veteran continually asserted that he does not want to be a "burden" on anyone but denied suicidal ideations. He reported having a hard time making day to day decisions about his life due to his worry regarding the "what if." When the Veteran's beloved dog passed away the Veteran's mental health declined for a number of days. The Veteran reported staying in bed most days and not showering or taking care of himself. The Veteran was asked if the veterinarian team should preform CPR on his dog which he described as "extremely triggering" due to the trauma he experienced in service. He further states that his OCD compulsions are interfering with his day to day life. The Veteran reports that his only outlet is smoking cigarettes and watching television. When the Veteran is stressed his mental health decreases even more. In June 2019, the Veteran reported that his OCD symptoms are resulting in physical injury to his wrist as he is forcibly checking windows and doors around his home to make sure they are locked. He now wears wrist braces to prevent further injury as he still compulsively checks his home for safety concerns. In July 2019 and August 2019 the Veteran reported ongoing instances of hypervigilance such as always being aware of the exits, siting with his back to a wall, avoiding social situations and crowds, feeling on guard at all times, and monitoring if people are acting suspicious or if they have a weapon. The Veteran also discusses ongoing instances of dissociation where he feels "out of body" while he relives his trauma. He reports still living in a constant state of worry where he does not have even a brief period of calm. The Veteran reports experiencing extreme anxiety, consistent panic attacks with his most recent instance lasting about 35 minutes. He describes feeling tapped and out of body during the panic attack but then feeling on edge worrying about when the next panic attack may come. He is not sleeping more than 3 to 4 hours per night and is waking up about every hour or so. He is in a constant state of worry that something bad will happen. The Veteran underwent an additional VA examination in November 2019. The examiner stated that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported that while he was still employed with the dental company, he did not socialize with his coworkers. The Veteran reported sleeping about 3 to 5 hours per night but is typically awoken due to his anxiety. The Veteran will then get out of bed, check all the doors, windows, outlets, and the stove for safety concerns. The Veteran continued to report having nightmares, flashbacks, feelings of impulsive aggression, anxiety, intrusive distressing thoughts related to safety concerns, and panic attacks. He did however continue to deny suicidal ideations. The Veteran had a VA individual psychotherapy session on December 18, 2018, the last day of the appeal period. He reported that work remained his primary stressor. He was employed as an office worker. He was trying not to perform OCD rituals in his office. His goal over the next three weeks was to not perform ritual safety checks on the second floor of his home, and he texted his wife, his "treatment buddy" to inform her of this goal. He and his therapist discussed using the stove at home once per day (he had not used it for years due to fear of causing a fire). He still having trouble falling and staying asleep and had constant intrusive thoughts leading to compulsive rituals "lasting 4-5 hours daily." Objective observations during the session were a calm and cooperative attitude; appropriate eye contact; spontaneous, fluent speech at a normal rate, rhythm, volume, and tone; euthymic affect with some anxiety; obsessive compulsive thought content; no suicidal or homicidal ideation; no evidence of audio or visual hallucinations; logical, goal-directed, coherent thought process; alert and oriented times three; grossly intact cognition; and fair judgment and insight. His therapist noted severe anxiety significantly affecting work and home life but had no acute safety concerns. Based on the evidence dated during the appeal period, the Veteran was employed and maintained a good relationship with his wife, who provided as much support as the Veteran could allow. The evidence does not show total occupational or social impairment. In June 2020, the Veteran's wife submitted a statement regarding the onset of the Veteran's mental health issues since he joined the Coast Guard in 2013. The Veteran's wife stated that since 2013 the Veteran's compulsions have been increasing in severity. The Veteran will take about 2 and a half hours to leave the house due to his compulsions and often times this leads to the Veteran not leaving the house at all. She also stated that after his traumatic experience in service regarding CPR the Veteran began to have "panic attacks and nightmares." His wife states that she now helps the Veteran through panic attacks almost daily. She concluded by stating the Veteran, "has gotten so much worse!" The Veteran's life-long friend also submitted a statement in June 2020. However, the letter did not specifically discuss the Veteran's symptoms for the period in question nor for the period directly after the Veteran's separation from service. In an August 2020 statement from the Veteran he asserts that the October 2017 VA examiner did not consider his OCD symptoms prior to forming the social and occupational impairment opinion. However, while the examination does not appear to note an OCD diagnosis, he does note that the Veteran's current mental health condition included "obsessive compulsive issues." While the examiner may not have specifically noted a diagnosis of OCD, the examination appears to have considered all of the Veteran's mental health symptoms as reported by the Veteran. Moreover, the Board does not base its conclusion solely on the level of impairment indicated by the examiner, but on the whole picture present by all the evidence. Additionally, in February 2021 the Veteran submitted a statement asserting that his condition has remained the same since his initial VA examination in 2017. However, the Veteran's wife in her June 2020 statement asserts that his condition has only continued to get worse over time. Additionally, the Veteran's VA mental health records show that while the Veteran has had significant symptoms throughout the entirety of the appeal period, his symptoms begin to escalate in late December 2019. See VA treatment records dated December 30, 2019. The Veteran and his wife are both competent to report on the observable symptoms of the Veteran's mental health conditions. See 38 C.F.R. § 3.159(a)(2). Additionally, his wife, who knew him prior to and after his active duty service, is competent to report the observable changes in the Veteran's mental health. Id. Furthermore, the Veteran is a credible source of information as he has recounted the same description of the onset his mental health conditions as well as symptoms consistent with those conditions in relation to the traumatic event experienced in service. However, the Board finds that the statements made during the Veteran's VA mental health appointments are more probative than the Veteran's assertion his symptoms have been static since he left service. White v. Illinois, 502 U.S. 346, 356 (1992) (Statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment). In summary, the Veteran's VA mental health records do not show that a 100 percent rating for his PTSD and accompanying mental health conditions is warranted prior to December 19, 2019 as his symptoms did not produce total occupational and social impairment during this stage. Throughout the period in question, the Veteran consistently denied having suicidal or homicidal ideations. The Veteran also consistently reported having a good relationship with his wife who often helped him through difficult moments when his mental health symptoms escalated. The Veteran also stated despite not sharing the details of his mental health issues with his family, he still has a close relationship with them. Additionally, the Veteran reported being employed with the dental company in October 2017 during his VA examination through December 18, 2019. The Board recognizes that during the appeal period the Veteran experienced frequent, severe, and serious symptoms. The 70 percent rating granted herein contemplates those symptoms and the social and occupational impairment they produce that results in deficiencies in the areas of mood, thinking, relationships, and work: obsessional rituals which interfere with routine activities; near-continuous panic affecting the ability to function independently, appropriately, and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work), and inability to establish and maintain effective relationships. During this stage, the evidence does not show symptoms of the frequency, severity, and duration to be on par with total social and occupational impairment, such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Entitlement to a rating of 70 percent, and no higher, for the period prior to December 18, 2019 is warranted. 38 C.F.R. § 4.130, Diagnostic Code 9411. The claim is granted. 2. Entitlement to service connection for TDIU. On June 22, 2021, a report of general information shows the Veteran called VA and stated they did not intend to appeal TDIU for this stage, but only the rating for PTSD. However, there has not been a written withdrawal of the issue conforming to 38 C.F.R. § 20.204(b) (redesignated as 38 C.F.R. § 19.55(b), effective February 19, 2019). The issue is still on appeal and must be adjudicated. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: provided that, if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). TDIU is not available from December 19, 2019, because the Veteran's schedular rating is not "less than total." Because he is in receipt of a 100 percent schedular disability rating for PTSD and SMC at the housebound rate, TDIU is not warranted. The Board finds that the Veteran was able to secure and follow a substantially gainful occupation prior to December 19, 2019. In considering entitlement to individual unemployability, the pertinent inquiry is whether service-connected disabilities individually or in combination are of sufficient severity to produce unemployability - not whether a Veteran is unemployable solely due to his service-connected disabilities. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Incorporating the grants herein, from March 12, 2017 to December 19, 2019, the Veteran's service-connected disabilities are as follows: PTSD rated at 70 percent disabling; tension headaches rated at 50 percent disabling; right shoulder A-C laxity condition rated at 20 percent disabling; cervical strain rated at 10 percent disabling; tinnitus rated at 10 percent disabling; right wrist chronic sprain associated with PTSD rated at 10 percent disabling effective March 26, 2019; left wrist chronic sprain associated with PTSD rated at 10 percent disabling effective March 26, 2019. As the Veteran had a single disability rated at least 60 percent disabling and a combined disability rating of at least 70 percent for the appeal period, he meets the schedular requirements for TDIU during the entirety of the appeal period. The Veteran has a bachelor's degree in aviation and during the appeal period was pursuing an MBA, though he took off the fall quarter of 2017. The Veteran separated from service on March 11, 2017. During a June 2017 VA mental health examination, the Veteran stated he was having difficulty with job interviews because he was "too anxious and angry." He also stated he was experiencing poor sleep habits, nightmares, flashbacks, intrusive thoughts, isolation, low energy, and poor concentration. The Veteran asserted these symptoms made it difficult to do his work. He was not employed at this time. From June 1, 2017 to August 15, 2017, he worked in management at a local fitness center. He voluntarily quit his position at the fitness center because it was stressful to take a job at a dental company that had better hours and a more understanding boss. See July-October 2017 VA treatment records; May 2020 VA Form 21-8940. Evidence shows the Veteran was employed full time with the dental company as a scheduler from September 1, 2017 through December 18, 2019. There is no indication that this employment was marginal. While the Veteran asserted in his May 2020 application for TDIU that he earned 25,000 dollars during his last year 12 months of employment at the dental office, the dental office reports the Veteran earned over 63,000 dollars in his last year. However, earning either salary would place the Veteran's income well above the poverty line. See Faust v. West, 13 Vet. App. 342, 355-356 (2000) (a substantially gainful occupation "provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days" actually worked). While his boss at the dental office was described as "more understanding" there is no indication that this was a sheltered work environment. See November 2019 VA examination report; VA treatment records. In a November 2017 VA mental health note, the Veteran stated that he has had opportunities to work in his field but purposefully chooses "entry level" positions due to the stress and anxiety he has experienced since his separation from service. The Veteran underwent a second VA examination in November 2019. Here, the Veteran stated he was still currently employed with the dental company. The Veteran stated that he did not socialize with his co-workers but denied any significant conflicts. The examiner concluded by stating that the Veteran had occupational and social impairment with reduced reliability and productivity. In July 2020 the Veteran submitted a statement that he left the fitness center position on bad terms as he had a "mental breakdown and quit suddenly." The Veteran further asserts that he quit this position as it was too stressful for his mental health condition. Specifically, the Veteran asserted that due to his flashbacks and nightmares regarding the traumatic event he experienced in service, he was too stressed to continue working. In August 2020 employment information from the fitness center was submitted. This report did not assert when the Veteran's employment began but does assert that his employment ended in August 2017. The Veteran worked seven to eight hours per day for a total of about 35 to 40 hours per week. No salary information was reported for the Veteran. However, the reason for termination stated that the Veteran quit his position "due to mental health and stress." However, the Veteran then went on to obtain full-time employment at the dental office in September 2017 and maintained full employment there until April 2020. Following a review of the record, the Board finds that the preponderance of the evidence does not support entitlement to TDIU prior to December 19, 2019. The Veteran's statements and statements by his former employers confirm he was substantially gainfully employed from June 1, 2017 to August 15, 2017 and September 1, 2017 through the end of the appeal period. The only periods during which he was not employed were for approximately 2.5 months immediately following separation from service, and for 16 days in August 2017. While the Veteran expressed difficulty interviewing and working during these times due to his symptoms, he also stated he has had opportunities to work in his field but purposefully chooses "entry level" positions. This statement weighs against a finding that he could not secure substantially gainful employment at any point during the appeal period. The Board also considered the Veteran's level of education, special training, and previous work. See 38 C.F.R. §§ 4.16. As noted above, the Veteran indicated that he has a bachelor's degree in aviation. In Hatlestad, 5 Vet. App. at 529, the Court held that the central inquiry in determining whether a Veteran is entitled to TDIU is whether a Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). While the Veteran's employment prior to December 19, 2019 was not in the field for which he earned a degree due to the stress it would cause him, he was still able to obtain employment which did not require special training and could be learned on the job site. Given that the Veteran, while not employed in his preferred area of expertise, was gainfully employed for the vast majority of the appeal period, and the evidence does not indicate that his symptoms prevented him from working during the other periods, entitlement to TDIU is not warranted. For the reasons stated above, the Board finds that the evidence weighs against a finding that the Veteran's service-connected disabilities rendered him unemployable or unable to secure and follow a substantially gainful occupation prior to December 19, 2019. 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). LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Associate Counsel, S. Conti 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.