Citation Nr: 22019149 Decision Date: 03/31/22 Archive Date: 03/31/22 DOCKET NO. 14-43 193 DATE: March 31, 2022 ORDER 1. Entitlement to service connection for a bilateral hip disability has been withdrawn and is dismissed. 2. Entitlement to service connection for a bilateral ankle disability has been withdrawn and is dismissed. 3. Entitlement to an increased disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) from June 28, 2011 is denied. 4. Entitlement to a total disability rating for compensation based upon individual unemployability due to all service-connected disabilities (TDIU) is denied. REMANDED 5. Entitlement to referral for consideration of an extraschedular TDIU rating based solely on PTSD is remanded. FINDINGS OF FACT 1. In November 2021, prior to the promulgation of a decision in the appeal, the Board received written notification from the Veteran's attorney that the Veteran wished to withdraw his claims of entitlement to service connection for bilateral hip and bilateral ankle disabilities. 2. For the entire period on appeal from June 28, 2011, the Veteran's PTSD has not been manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 3. For the entire period on appeal, the Veteran was not precluded from securing or following a substantially gainful occupation due to all of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claim of entitlement to service connection for a bilateral hip disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of the claim of entitlement to service connection for a bilateral ankle disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for an increased disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code (DC) 9411. 4. The criteria for TDIU due to all of the Veteran's service-connected disabilities have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1965 to November 1967. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a January 2019 videoconference hearing and a transcript of the hearing has been associated with the claims file. In August 2019, the Board denied the Veteran's claims on appeal, after which the Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court). Pursuant to a June 2020 Joint Motion for Remand (JMR), a July 2020 Court Order remanded the matters for action consistent with the terms of the JMR. Given the Veteran's subsequent withdrawal of his service connection claims for a bilateral hip and bilateral ankle disability, no further development is warranted regarding those claims. To the extent the June 2020 JMR identified deficiencies regarding the Veteran's increased rating for PTSD and TDIU claims, those matters are addressed further herein. 1. Entitlement to service connection for a bilateral hip disability. 2. Entitlement to service connection for a bilateral ankle disability. The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55. In November 2021, prior to the promulgation of a decision in the appeal, the Board received written notification from the Veteran's attorney that the Veteran wished to withdraw his claims of entitlement to service connection for bilateral hip and bilateral ankle disabilities. As such, the Veteran has properly withdrawn the appeal concerning the claims for service connection for bilateral hip and bilateral ankle disabilities and, hence, there remain no allegations of errors of fact or law for appellate consideration with respect to these claims. Accordingly, the Board does not have jurisdiction to review the matters of entitlement to service connection for bilateral hip and bilateral ankle disabilities, and they are dismissed. 3. Entitlement to an increased disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) from June 28, 2011. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Regarding the relevant temporal period for the Veteran's increased rating claim for PTSD, the June 2020 JMR found that the August 2019 Board decision inaccurately characterized the appeal period from April 2012, one year prior to the Veteran's April 2013 increased rating claim. The record reflects that following his initial September 29, 2010 claim for service connection for PTSD, a March 2011 rating decision granted service connection for PTSD and assigned a 30 percent disabling. Thereafter, the Veteran submitted a June 2011 statement seeking reconsideration of the initial 30 percent disability rating. Notably, the June 2011 statement did not express dissatisfaction or disagreement with the March 2011 decision and indicate a desire to contest the result. Thus, it is considered a request for a reconsideration and not a notice of disagreement (NOD). 38 C.F.R. § 20.201. In a subsequent October 2011 rating decision, the RO continued the initial 30 percent disability rating, after which the Veteran filed a timely NOD with that decision in November 2011 and specifically wrote he was seeking an increased 50 percent disability rating. Thereafter, a December 2012 rating decision granted an increased 50 percent disability rating for PTSD from June 28, 2011. In the January 2013 notification letter to the Veteran, the RO wrote, "This Grant Represents A Full Grant of Benefits Sought On Appeal." (Bold in original.) This letter also informed the Veteran that if he did not agree with this decision, he should write to VA and tell it why. It attached a copy of the December 2012 rating decision. Within the rating decision, at the end of the reasons and bases wherein the RO explained it was granting a 50 percent rating for PTSD but not a 70 percent rating, the RO wrote, "THIS GRANT REPRESENTS A FULL GRANT OF BENEFITS SOUGHT ON APPEAL. Your notice of disagreement indicated you were seeking a 50 percent evaluation." (Bold and upper case in original.) In April 2013, the Veteran submitted a VA Form 21-526b, Veteran's Supplemental Claim for Compensation, wherein he wrote he was seeking an increased evaluation for PTSD. Within the April 2013 submission, there was no expression of a disagreement and a desire for appellate review. Thus, the April 2013 claim for increase is not an NOD. To the extent that the Veteran's November 2021 brief asserts that his increased rating claim has been pending since September 29, 2010, when he first submitted his service-connection claim, the Board disagrees. As noted above, the Veteran did not submit a timely NOD following the March 2011 rating decision, but rather, a request for reconsideration. Additionally, the November 2011 NOD specifically sought a 50 percent disability rating, which was subsequently granted, and it is significant that after the December 2012 rating decision, the Veteran did not express disagreement with the effective date of the award of the increased 50 percent disability rating. Given the above, and in order to fully afford the Veteran the benefit of the doubt, the Board agrees that the record indicates that the Veteran's increased rating claim for PTSD predates April 2012, and the Board will address the Veteran's claim for an increased disability rating in excess of 50 percent from the effective date of that increased rating, June 28, 2011, which effective date the Veteran did not appeal. The Veteran's service-connected PTSD is currently rated as 50 percent disabling from June 28, 2011 under Diagnostic Code (DC) 9411 of the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under the applicable rating criteria, a 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; 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. A 70 percent disability rating is warranted 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. Finally, a 100 percent disability rating is warranted 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. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. The use of the term "such as" in the rating criteria demonstrates that the symptoms after that 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. Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. In Golden v. Shulkin, 29 Vet. App. 221 (2017), the Court held that since the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. Because the current appeal was certified to the Board in April 2017, the Board will not rely on GAF scores when analyzing the merits of the Veteran's increased rating claim for PTSD on appeal. As discussed below, following a review of the evidence of record, the Board finds that the evidence persuasively weighs against the Veteran's claim of entitlement to an increased disability rating in excess of 50 percent for PTSD for the entire period on appeal from June 28, 2011. The reasons for this decision follow. Turning to the evidence of record, VA treatment records from June 2011 document the Veteran's complaints of active symptoms associated with trauma-related pathology including re-experiencing, hyperarousal, and avoidance, as well as symptoms related to his son's development of two, different cancers over his lifetime and his struggles with recovery, which he believed may be associated with his potential exposure to Agent Orange. He reported lability of affect and mild depressive symptoms on a seasonal basis only, but denied any active suicidal ideation, history of suicide attempt, or any active alcohol or substance abuse or related treatment. The psychologist wrote the Veteran displayed mildly anxious and dysphoric mood with restricted affect, but did not demonstrate symptoms consistent with current suicidal ideation, homicidal ideation, or auditory or visual hallucinations. He appeared alert and oriented, with fair insight, good judgment, and speech which was logical, coherent, and sequential. Upon VA PTSD examination in August 2011, the Veteran reported that he continued to live with his wife of more than 39 years and his 34-year-old son. He stated that he previously worked as a manager for a book bindery for over 24 years but noted he had not worked in competitive employment since 2008, when he began Social Security retirement. He also noted that he was sent to an anger management program prior to his retirement. He reported an initial mental health appointment with a psychologist in May 2011, following his initial VA mental health examination with no psychotropic medication being prescribed. The VA examiner noted the Veteran's psychiatric symptoms including depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), and disturbances of motivation and mood. The examiner concluded that the Veteran's PTSD resulted in 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. Additionally, the examiner noted that the degree of emotional turmoil asserted by the Veteran was not consistent with PTSD avoidant symptoms, psychiatric treatment access/history, or test taking validity indicators, and that the Veteran's PTSD symptom severity as reported was not corroborated by clinical interview, treatment history, or behavioral report. An August 2011 letter from the Veteran's Vet Center counselor noted support of the Veteran's claim due to an increase in having weekly panic attacks of no less than three times a week, which caused the Veteran to isolate and not be able to attend family functions, as well as symptoms including a severe sleep disorder, irritability which rendered him unable to function, and difficulty remembering to do chores around the house, which included remembering to keep important appointments, such as medical and psychiatric. VA treatment records from September 2011 document a positive depression screen, which was suggestive of moderately severe depression. Upon examination, the Veteran was alert and oriented and displayed mildly anxious and dysphoric mood with restricted affect, but he denied and did not demonstrate symptoms consistent with current suicidal ideation, homicidal ideation, or auditory or visual hallucination. His speech was logical, coherent, and sequential, while his insight appeared fair, with good judgment. A follow-up treatment record from the following month, in October 2011, documents that the Veteran was participating in VA group psychotherapy. Vet Center treatment records from April 2012 through February 2013 document the Veteran's participation in biweekly to monthly individual therapy. Therein, he was assisted with learning how to cope with emotions, triggers, and improving his sleep by refocusing through new hobbies and exercise. In February 2013, the Veteran's counselor stated that the Veteran had the capacity to gain control of his emotions during a negative situation and that he could be successful in dealing with stress and had the ability to move on. Upon VA PTSD examination in February 2014, the Veteran reported that he was controlling his emotional state by not putting himself in situations that irritate him. He stated that was not working but supported himself with his pension and savings. He reported monthly attendance at Vet Center individual counseling sessions but stated that he did not attend group meetings because he could not tolerate other people's problems and preferred to be by himself. He denied hospitalizations, suicide attempts, or additional mental health treatment. Additionally, he denied medications, arrests, gambling, DUIs, violent outbursts, or behavioral disturbances. The VA examiner noted psychiatric symptoms of depressed mood and anxiety and diagnosed PTSD, which resulted in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood. The examiner remarked that the Veteran presented as a depressed individual who has trouble managing unpleasant and uncomfortable emotions with anger and a negative view of himself and the world. The examiner noted that there did not seem to be many changes from the previous evaluation, but stated the Veteran was preoccupied with his son's emotional and occupational functioning. Within the April 2014 NOD, the Veteran wrote that the February 2014 VA PTSD examination was inadequate because it lasted approximately 15 minutes, and the VA examiner was not thorough and asked no questions regarding the frequency of his panic attacks, social and occupational impairment, or any other symptoms. Similarly, within the October 2014 VA Form 9, Appeal to the Board, the Veteran asserted that VA had failed to consider the economic impact of his PTSD. He stated that he had lost his last two jobs due to an inability to maintain effective relationships in a work environment, which he felt was a direct result of impaired impulse control with unprovoked irritability and periods of violence. Additionally, he reported memory loss and near-continuous panic attacks that also affected his ability to function in a work environment. Upon VA PTSD examination in December 2015, the Veteran reported difficulty sleeping with nightmares and constant rumination, as well as avoidance, isolation, irritability, depression, and memory problems. For example, he reported that he would leave doors open, burn things, and that his wife constantly reminded him to do things. He was also preoccupied with his son's medical and occupational problems and blamed his tour of duty in Vietnam for his son's medical problems. He stated that had tried to work but could not hold a job and stated that he refused to take his prescribed psychiatric medication or to attend group therapy. Upon mental status examination, he appeared alert and oriented, with normal speech and sad affect as he discussed his son's medical problems. There were no perceptual disturbances noted, his judgment and insight appeared to be good, and he denied any suicidal or homicidal ideation. His dressing, grooming, and hygiene were neat and appropriate. The examiner identified psychiatric symptoms including depressed mood, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), and impairment of short- and long-term memory (for example, retention of only highly learned material, while forgetting to complete tasks), all of which resulted in PTSD with occupational and social impairment with reduced reliability and productivity. The examiner concluded that the Veteran's symptoms were unchanged since his last examination and that the intensity of the Veteran's symptoms remained the same. A December 2015 letter from a Vet Center counselor reported that the Veteran continued to experience poor sleep with nightmares for the past two years that had intensified to at least three times per week. The Veteran also reported social isolation from others, including his immediate family, and decreased social activities due to the lack of ability to interact with others. He also noted flashbacks on an average of three times per week, panic attacks, and dissociative reactions. At one time, the Veteran enjoyed traveling and being outdoors, but throughout the past year, these activities had diminished. The counselor also noted that he had lost numerous jobs due to his anger and inability to maintain his composure. The Veteran reported that he gets quick tempered with little provocation at least twice per week and this causes him to have negative relationships, especially between him and his wife. The counselor concluded that the Veteran's PTSD had worsened to the point that he was unable to be gainfully employed. VA treatment records from August 2016 document the Veteran's worsening depression since the death of his spouse in May 2016, although he denied any suicidal or homicidal ideation. He also reported ongoing family stress regarding his son. In October 2016, the Veteran submitted a statement contained on a VA Form 9 wherein he asserted that he had at least three of the symptoms listed under the criteria for a 70 percent disability rating, including near-continuous panic or depression affecting the ability to function independently, appropriately, and effective; impaired impulse control (such as unprovoked irritability with periods of violence); and difficulty in adapting to stressful circumstances (including work or a worklike setting). VA treatment records from October 2018 document that the Veteran continued to struggle with stressors, including the death of his wife (which he continued to blame himself for because he took some medication and slept through the night that she died) and struggles with his son's health problems. Upon mental status examination, he appeared alert and oriented, with appropriate dress and grooming, and normal speech, thoughts, judgment, and insight, without any thought disorder or suicide risk. He also discussed the benefits of an emotional support dog in assisting him to cope with his stress and anxiety and requested a letter in support of owning an emotional support animal. That same month, the Veteran's VA psychologist provided the requested letter, which prescribed an emotional support animal to enhance the Veteran's ability to live independently and to help him manage and alleviate his PTSD symptoms, including social limitations, stress, depression, and anxiety. Upon his most recent VA PTSD examination in November 2018, the Veteran reported no changes in his living situation. He continued to live alone after the death of his wife in 2016 and experienced loneliness and grief over her death. He reported that he stopped working 10 years ago and had not worked since that time. He denied any psychiatric hospitalization or outpatient mental health treatment since his last VA examination and was not taking his prescribed psychotropic medication. He reported symptoms including difficulty concentrating, forgetfulness, depression, sleep impairment with nightmares, loss of appetite, anhedonia, anger, irritability, and constant thoughts and ruminating on the loss of his wife. He denied legal or behavioral problems as well as substance abuse. Upon mental status examination, the Veteran was alert, oriented, appropriately attired, and well groomed. He was cooperative and conversational, with normal speech, thought processes, cognition, and attention throughout. His judgment and insight were intact, and he denied suicidal or homicidal ideation. The VA examiner concluded that the Veteran's PTSD symptoms of depressed mood, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), and disturbances of motivation and mood resulted in overall 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 which were controlled by medication. The examiner further remarked that the current severity level of Veteran's PTSD, which had not changed since his last exam, was mild to moderate. At the January 2019 Board hearing, the Veteran testified that his PTSD symptoms were due to Vietnam, where his good friend was killed, as well as his guilt over the death of his wife after he took a pill to help him sleep on the night that she died and then could not wake up. He also discussed that his son's various health problems and complications added stress to his life, and he could not rest. He stated that he could lose it emotionally at any time and reported that he was fired twice in the past, first in 1981 after threatening to throw his boss through a window and again in approximately 2008 after he lost control of his emotions and raised his voice. VA treatment records from April 2019 document the Veteran's participation in family therapy, which he found to be helpful. He realized that he was acting too much like his son's "guardian angel" and they discussed healthy boundaries to foster symptom relief and have his son develop more autonomy. Upon mental status examination, the Veteran was alert, oriented, and appropriately dressed and groomed, with normal speech and thought processes, and intact judgment and insight. He denied audiovisual hallucinations, delusions, and suicidal or homicidal ideation. He stated that he "was a mess" but that he was "feeling more relief." During an October 2021 private evaluation by Michael L. Cesta, MD, the Veteran reported that he could no longer tolerate functioning within the workforce after 2008. He described being married upon returning home from service but stated the marriage was strained due to his mental illness. He also described his son as having significant neurologic disease and dedicating himself to his child's well-being. The Veteran stated that after Vietnam, he utilized alcohol extensively but decreased his use after his son was born, and noted that his use of alcohol mitigated the symptoms of PTSD, as it was the only way he would be able to function at work and home. He noted that when he stopped using alcohol or diminished his use significantly, the symptoms of PTSD would become exponentially worse, especially nightmares and dissociative episodes. The Veteran endorsed current symptoms including a fairly reclusive lifestyle and indicated little belief in the mental health system. He stated that after his initial evaluation in 2011, he participated in individual therapy for a few years, but since then has had infrequent interactions with the mental health care system, although he stated that he returned to psychiatric service after he recognized his increasing avoidance, worsening dissociative episodes, daily nightmares, and detachment from any previous acquaintances, friends, or family, and described persistent neurovegetative symptoms of depression in addition to anhedonia, guilt, frequent suicidal ideation, irritability, and low frustration tolerance. He indicated that he found little benefit from mental health care service and has little hope of improving. Dr. Cesta wrote that during mental status examination, the Veteran was cooperative and appropriate, with reasonable impulse control. His speech was pace and decreased in rate, tone, and volume. He was not agitated, his mood was "fine," and his affect was severely flattened and restricted with periods of anger. Thought content was positive for passive suicidal ideation, without homicidal ideation or delusions, and thought processing was marked by thought blocking, without flight of ideas or looseness of associations. He did not endorse any perceptual alterations, such as auditory, visual, or tactile hallucinations, and he was cognitively intact. Dr. Cesta noted that the Veteran's clinical presentation was consistent with a formal diagnosis of PTSD, with dissociative symptoms, with delayed expression. He stated that this disease process had progressed steadily since its onset after the Veteran's return from Vietnam, and noted that the Veteran not only had the classic constellation of PTSD symptomatology, but had experienced severe neurovegetative symptoms of depressions, hopelessness, helplessness, despair, and rumination, which constellation of symptoms includes alterations in focus, concentration, and memory. Dr. Cesta noted that the Veteran used an array of maladaptive coping mechanisms, including alcohol abuse and avoidance, to suppress his symptoms. The Veteran reported that although he managed to work with some success, he frequently engaged in verbal altercations and even exhibited threatening behavior, and, on several occasions, he was reprimanded for such behavior and was even advised to seek anger management counseling. Dr. Cesta wrote that due to the Veteran's resistance to seek formal treatment and the severity of his condition, the Veteran's disease process progressed unfettered, ultimately becoming an intractable clinical condition. Dr. Cesta wrote that by June 2008, the Veteran reported that he left the work force due to his inability to interact with others appropriately. Dr. Cesta noted that since leaving the workforce, the Veteran had learned to manage his anger by retreating inwards and largely avoiding any potentially triggering situation or interactions with people outside his immediate family, which had been effective in limiting his angry outbursts, but he stated that it would not be feasible in a gainful employment setting, as virtually any job requires the ability to cope with stress and interact routinely with coworkers, supervisors, and/or the public. As such, Dr. Cesta stated that the Veteran's coping mechanisms prevent him from meeting those basic requirements of gainful employment, thereby preventing him from functioning adequately in a workplace. Dr. Cesta noted that the Veteran's treating therapist assessed his PTSD symptomatology as severe and disabling, whereas VA examinations had described it as mild to moderate, and stated, that overall, the record shows the Veteran suffers from frequent panic attacks, crying spells, memory loss, verbal outbursts impacting his familial relationships and work, losing employment due to excessive anger, social isolation, and excessive ruminations. He stated that the suggestion that the Veteran's symptoms caused mild impairment only is at odds with his review of the medical record and interview of the Veteran, both of which revealed the Veteran to be profoundly disabled due to his neurovegetative depressive symptomatology, cognitive dysfunction, and outbursts of anger. However, he also noted that his review of the medical record revealed that the Veteran had at times struggled to articulate the extent and severity of his psychiatric symptomatology. Dr. Cesta wrote that while the Veteran had insight that his mental health condition causes significant impairment, he often focuses on external factors, such as his son's own health and his wife's death, rather than how his PTSD symptoms affect his own life. Dr. Cesta stated that this was evident during the interview, and it took time and careful probing before the Veteran was willing to discuss the specific ways his PTSD impacts his daily life. Given the Veteran's reticence, Dr. Cesta stated that he was not surprised that the exam reports completed by unfamiliar examiners would underestimate the severity and impact of the Veteran's PTSD symptoms. In this context, he considered the evaluations from the Veteran's long-time therapist, who has had the opportunity to build trust and rapport with the Veteran, to provide a more accurate description of the Veteran's overall impairment. Regarding his prior employment history, Dr. Cesta noted that the Veteran had a well-documented propensity for outbursts in the workplace, and that since leaving the workplace, he had become profoundly isolated and struggled with basic interpersonal interactions, which would prohibit him from returning to his past work as a supervisor in a book binding company. Additionally, Dr. Cesta stated that the Veteran's diminished cognitive functioning, impaired memory, and poor task completion would significantly limit the number and types of jobs available to him. Given the combination of these limitations, as well as his high school education, Dr. Cesta opined that the Veteran has been unable to function in a gainful occupation environment due to his PTSD since June 2008. Following a review of the evidence of record, including that discussed above, the Board finds that the evidence persuasively weighs against an increased disability rating in excess of 50 percent for PTSD for the entire period on appeal, as the Veteran's PTSD symptomatology does not more closely approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Board has also considered the severity, frequency, and duration of the mental health symptoms displayed by the Veteran during the appeal period; however, it finds that the Veteran's mental health symptoms are not of such severity, frequency, and/or duration to more nearly approximate occupational and social impairment with deficiencies in most areas for any period on appeal. Specifically, the objective evidence discussed above documents that the Veteran's PTSD has not been manifested by such symptoms as suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; or neglect of personal appearance and hygiene for any period on appeal. Regular VA examinations in February 2014, December 2015, and November 2018, as well as ongoing mental status examinations document the Veteran's repeated and consistent denials of suicidal ideation, a lack of obsessions or delusions, and normal speech, orientation, appearance, and hygiene. To the extent that the Veteran has reported ongoing irritability that could be considered as impaired impulse control under the rating criteria for a 70 percent disability rating, the Board notes that the evidence persuasively weighs against a finding that the Veteran's irritability, even unprovoked irritability, has resulted in periods of violence for any period on appeal. Rather, the Veteran specifically denied violent outbursts during the February 2014 VA examination, and the December 2015 Vet Center counselor indicated that the Veteran's outbursts at his wife and co-workers were verbal in nature. As such, this evidence does not weigh in favor of an increased 70 percent disability rating. Since the death of his wife in 2016, the Veteran has consistently reported ongoing, even constant, symptoms of depression, as well as panic attacks. Notably, however, the probative evidence does not support a finding that such depression or panic has affected his ability to function independently, appropriately, and effectively. As recently as October 2018, the Veteran's VA psychologist prescribed an emotional support animal for the specific purpose of enhancing the Veteran's ability to live independently and to help him manage and alleviate his PTSD symptoms. Similarly, during the November 2018 VA examination, the Veteran stated that he continued to live alone after the death of his wife in 2016. Such evidence is highly probative and shows that the Veteran retained the ability to function independently. The Board has also considered the Veteran's assertions of difficulty in adapting to stressful circumstances (including work or a work-like setting), or an inability to establish and maintain effective relationships. Upon VA examination in February 2014, the Veteran reported that he was controlling his emotional state by not putting himself in situations that irritate him, and he also avoided attendance at group meetings because he could not tolerate other people's problems. The Board is mindful that the June 2020 JMR found that the Board previously failed to explain how avoidance of stressful circumstances, as reported upon examination in February 2014, is evidence of an absence of difficulty adapting to stressful circumstances. Indeed, the parties stated that the Veteran's avoidance of stressful circumstances could even have been because of such difficulty adapting to stressful circumstances. Nevertheless, the Board emphasizes again that the Veteran's own report that he was learning to control his emotional state by avoiding stressful situations is probative evidence of some ability to adapt to stressful circumstances, as the Veteran was proactive in his responses to situations that he knew would result in stressful circumstances. Similarly, the parties within the June 2020 JMR noted the Board's prior finding that the Veteran's ability to establish relationships, though impaired, was not completely lacking, because he attended counseling and established relationships with Vet Center and VA therapists. However, the parties agreed that it was unclear how obtaining treatment for PTSD by attending counselling sessions shows an ability to establish and maintain relationships. The Board acknowledges that the Veteran's attendance at counseling/therapy sessions may be necessitated by symptomatology, such as an impaired ability to establish and maintain relationships; however, the Board also finds that the Veteran's attendance at mental health counseling sessions is indicative of at least some ability to establish even minimal therapeutic relationships with his VA and Vet Center therapists. Moreover, the record clearly reflects that the Veteran has at least an ability to establish and maintain relationships outside of his therapeutic relationships with counselors and therapists, as he has maintained strong family relationships with his spouse and son throughout the appeal period and has documented ongoing concern for his son's wellbeing and expressed sincere grief after his wife's death in 2016. At the time of his wife's death, the Veteran and his wife had been married for more than 40 years. Therefore, while the Board concedes that the Veteran's ability to establish and maintain effective relationships may have been impaired due to his PTSD symptoms, any such impairment is adequately contemplated by his current 50 percent disability rating, as he was not unable to establish and maintain effective relationships for any period on appeal. The 50 percent rating contemplates difficulty in establishing and maintaining effective relationships. Thus, this symptom is specifically considered by the 50 percent rating. As such, this evidence likewise does not warrant the assignment of an increased 70 percent disability rating. Regarding the Veteran's April 2014 NOD, wherein he asserted that the February 2014 VA PTSD examination was inadequate because it lasted only 15 minutes and was not thorough, the Board finds the Veteran's conclusory assertion of inadequacy to be without merit. A review of the February 2014 VA examination report shows that the examiner documented the Veteran's social/marital/family history, the relevant occupational history, relevant educational history, mental health history, relevant legal issues and behavioral history, substance abuse history, how the Veteran's symptoms meet the criteria for a diagnosis of PTSD, the symptoms that applied to the Veteran's diagnosis, and his observations during the examination. The February 2014 VA examiner addressed the Veteran's own report of his symptoms, such as he was controlling his emotional state by not putting himself in situations that irritated him, the examiner documented the Veteran continued to attend regular counseling sessions, he specifically denied violent outbursts, and he remained concerned with the care and well-being of his son. As such, the Board finds that the February 2014 VA examination is adequate. The Board is mindful that the February 2014 VA examiner specifically concluded that the Veteran's psychiatric symptoms resulted in occupational and social impairment with deficiencies in most areas; however, the Board as adjudicator is responsible in determining which disability rating is warranted. Additionally, it must be noted that when the examiner is asked which of the following best summarizes the Veteran's level of occupational and social impairment with regard to the mental diagnoses, it does not include a list of symptoms that are examples of that level of severity. Thus, the VA examiner is not making an informed determination based on the cursory description of "occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood." Within the February 2014 VA examination report, the examiner checked that the Veteran had "depressed mood" and "anxiety." The Board finds that the level of severity of the clinical findings documented within the February 2014 VA examination report do not more closely resemble the level of severity of the symptoms contemplated by the 70 percent rating. Moreover, the subsequent December 2015 VA examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity, which is consistent with his currently assigned 50 percent disability rating. More recently, the November 2018 VA examiner identified 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, which is consistent with the rating criteria for a 10 percent disability rating. As above, the Board as adjudicator is responsible in determining which disability rating is warranted. Similarly, aside from the February 2014 VA examiner's cursory conclusion and the December 2015 Vet Center counselor's statement that the Veteran lacked the ability to interact with others and was unable to be gainfully employed (which is inconsistent with the evidence discussed above documenting his ongoing relationships with various counselors and family members), no other VA examiner or treating mental health professional has concluded that the Veteran's PTSD has resulted in worse than occupational and social impairment with reduced reliability and productivity. Additionally, although the Veteran, within the October 2014 VA Form 9, asserted that he had an inability to maintain effective relationships in a work environment, impaired impulse control with unprovoked irritability and periods of violence, memory loss, and near-continuous panic attacks that affected his ability to function in a work environment, the Board finds that such assertions are outweighed by other, more probative evidence discussed above. While the Veteran has reported he was apparently fired from his last two jobs due to disagreements and verbal outbursts, as discussed above, there is no probative evidence that he displayed periods of violence towards anyone. Additionally, information obtained from his prior employer, Cadmus Communications, indicates that the Veteran was employed there from April 1985 to June 2008, when he was terminated from his position as a supervisor due to a violation of company policy. Though further detail regarding his termination was not provided, the Veteran testified in January 2019 that he was fired in approximately 2008 after he raised his voice. Such evidence does not weigh in favor of a finding that the Veteran exhibited violence at work. He worked at Cadmus for more than 20 years. Similarly, the Veteran's October 2016 lay statement that he had at least three of the symptoms listed under the criteria for a 70 percent disability rating, including 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); and difficulty in adapting to stressful circumstances (including work or a worklike setting) are also outweighed by the probative evidence discussed in detail above. Moreover, the Veteran's own testimony at the January 2019 Board hearing reported that he was fired from two previous work positions after he lost control of his emotions and raised his voice. This evidence weighs against a finding that his irritability resulted in periods of physical violence, or any worse than vocal outbursts. Finally, the Board has considered the October 2021 private evaluation by Dr. Cesta, but finds that it is of less probative value than the VA examinations of record discussed above. Notably, during Dr. Cesta's interview, the Veteran had a normal mental status examination, without documentation of obsessional rituals that interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; or neglect of personal appearance and hygiene. To the extent that the Veteran reported to Dr. Cesta that he experienced frequent suicidal ideation, which could potentially warrant an increased disability rating, the Board finds that this isolated report is of lessened probative value, as it is inconsistent with the Veteran's prior examinations and treatment records, all of which do not document reports of suicidal ideation by the Veteran. Additionally, to the extent that Dr. Cesta concluded that it would not be feasible for the Veteran to use his learned ability to manage his anger by avoiding any potentially triggers in a gainful employment setting, as "virtually any job requires the ability to cope with stress and interact routinely with coworkers, supervisors, and/or the public," the Board disagrees with this assessment. Rather, the fact that the Veteran had learned to control his impulsive outbursts is probative evidence that his psychiatric disability is less severe than that which is contemplated by an increased 70 percent disability rating, with occupational and social impairment with deficiencies in most areas. Although Dr. Cesta concluded that the Veteran's coping mechanisms prevent him from meeting the basic requirements of gainful employment, thereby preventing him from functioning adequately in a workplace, the Board finds that there are available jobs that exist that would allow the Veteran to avoid direct and even frequent interaction with coworkers and/or the public. Additionally, while Dr. Cesta disagreed with prior VA examinations that found the Veteran's condition was mild to moderate and stated such findings were "at odds" with his finding that the Veteran was "profoundly disabled due to his neurovegetative depressive symptomatology, cognitive dysfunction, and outbursts of anger," the Board notes that Dr. Cesta did not state why he agreed with the findings of the prior Vet Center therapist, who assessed the Veteran's PTSD symptomatology as severe and disabling, over the conflicting findings of the VA examiners discussed above. As noted above, the December 2015 Vet Center counselor's statement that the Veteran lacked the ability to interact with others and was unable to be gainfully employed has been found to be inconsistent with the other evidence of record documenting the Veteran's ongoing therapeutic relationships with various counselors, as well as his strong familial relationships. Dr. Cesta also noted that the Veteran had, at times, struggled to articulate the extent and severity of his psychiatric symptomatology, and, as such, he was not surprised that the prior VA examination reports "completed by unfamiliar examiners" would underestimate the severity and impact of his PTSD symptoms. Notably, however, Dr. Cesta's own assessment was based upon one isolated interview of the Veteran, as well as the Veteran's own lay reports concerning the severity of his symptoms; therefore, it is unclear why the Veteran's ability to articulate the extent and severity of his psychiatric symptoms would be any different for Dr. Cesta as opposed to the prior VA examiners. For all these reasons, the Board affords Dr. Cesta's opinion concerning the severity of the Veteran's PTSD to be a less probative value than the VA examination reports, which were completed contemporaneously with the times of the examinations. The Veteran's current 50 percent disability rating for PTSD already contemplates occupational and social impairment; however, the evidence persuasively weighs against a finding that the Veteran has shown deficiencies in most areas to warrant an increased 70 percent disability rating for all the reasons laid out above. As the Veteran's psychiatric symptoms do not meet the rating criteria for an increased 70 percent disability rating for any period on appeal, it follows that such symptoms also do not meet the more severe rating criteria for an increased 100 percent disability rating for the appeal period. Significantly, the Veteran has not shown the required severity of occupational and social impairment necessary for an increased 70 or 100 percent disability rating during the period on appeal, and his psychiatric symptoms as a whole are not of similar severity, frequency, and duration as those particular symptoms associated with an increased 70 or 100 percent disability rating. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether an increased disability rating in excess of 50 percent for PTSD is warranted. Rather, the evidence persuasively weighs against an increased disability rating in excess of 50 percent for PTSD for the entire period on appeal, as the Veteran's PTSD symptoms do not more closely approximate occupational and social impairment with deficiencies in most areas. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Given the above, the Veteran's claim for an increased disability rating in excess of 50 percent for PTSD is denied. 4. Entitlement to TDIU due to all service-connected disabilities. The Veteran has previously asserted that he is precluded from securing or following a substantially gainful occupation due to his all of his service-connected disabilities. To the extent that a November 2021 brief submitted by the Veteran's representative explicitly requests that BVA consider TDIU based solely on the Veteran's PTSD symptoms, that specific issue is discussed further in the remand section below. Given that the June 2020 JMR addressed deficiencies related to the Board's prior analysis of TDIU as to whether the Veteran's service-connected carpal tunnel syndrome (CTS) and hearing loss resulted in "complete preclusion" of the ability to work, the Board will proceed to consider immediately below whether the Veteran is unable to secure or follow a substantially gainful occupation due to all of his service-connected disabilities during the period on appeal. A TDIU rating may be granted upon a showing that a veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. There are minimum disability rating percentages that must be shown for the service-connected disabilities, alone or in combination, to even qualify for consideration for a TDIU award under the schedular criteria. Indeed, if there is only one such disability, it must be rated at 60 percent or more; if instead there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. For the purpose of determining whether a veteran meets the criteria for assigning a schedular TDIU, disabilities resulting from a common etiology and disabilities affecting a single body system are considered to be one disability. In determining whether a veteran is unemployable for VA purposes, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. The central inquiry in determining whether a Veteran is entitled to a TDIU rating is whether service-connected disabilities alone are of sufficient severity to produce unemployability. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough; a high disability rating itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. The ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; rather, it is a determination for the adjudicator. 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). The Veteran is currently service connected for coronary artery disease (rated as 60 percent disabling from February 28, 2019), PTSD (rated as 30 percent disabling from September 29, 2010 and as 50 percent disabling from June 28, 2011), right upper extremity CTS (rated as 30 percent disabling from April 10, 2013, as noncompensable (0 percent disabling) from March 16, 2016, and as 40 percent disabling from December 5, 2017), left upper extremity CTS (rated as 20 percent disabling from April 10, 2013, as noncompensable (0 percent disabling) from January 15, 2016, and as 30 percent disabling from December 5, 2017), tinnitus (rated as 10 percent disabling from September 29, 2010), and bilateral hearing loss (rated as noncompensable (0 percent disabling) from September 29, 2010. Given the above, the Veteran's combined disability rating is 40 percent from September 29, 2010, 60 percent from June 28, 2011, 80 percent from April 10, 2013, 70 percent from January 15, 2016, 60 percent from March 16, 2016, 80 percent from December 5, 2017, and 90 percent from February 28, 2019. The Board is mindful that the Veteran's service-connected disabilities share a common etiology (based on his active service in Vietnam), and as such, he meets the schedular criteria requirements for TDIU throughout the relevant period on appeal. Following a review of the evidence of record, and as discussed below, the Board finds that the evidence persuasively weighs against the Veteran's claim of entitlement to a TDIU rating based upon all of his service-connected disabilities for the entire period on appeal, as the probative evidence of record does not document that the Veteran's service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation during the appeal period. The reasons for this determination follow. Within his December 2015 VA Form 21-8940, Veteran's Application for Increased Compensation Based Upon Individual Unemployability, the Veteran asserted that he was prevented from securing or following substantially gainful occupation due to his service-connected disabilities. He reported that he last worked full time in June 2009 as a manager. He noted that he left his last job due to disability and stated that he had tried to obtain employment from 2009-2011. He further reported an educational history including four years of high school and additional business management training and computer training. In January 2016, the Veteran's previous employer, Cadmus Communications, reported that the Veteran worked there from April 1985 to June 2008, when he was terminated from his supervisor position due to a violation of company policy. Regarding the Veteran's service-connected CAD, the Board is mindful that an April 2019 VA heart examination revealed functional impact upon his ability to work, including symptoms of fatigue, dyspnea, and dizziness with strenuous activities. Notably, however, the Board cannot equate the examiner's finding regarding functional impairment resulting from strenuous activities with a finding that the Veteran was precluded from securing or following a substantially gainful occupation. Notably, the Veteran's prior work experience as a manager in an office environment does not appear to have required strenuous physical activity; therefore, it is unlikely that his service-connected heart disability would have impaired his ability to function in that position. Regarding the Veteran's service-connected CTS of his bilateral upper extremity, the Board notes that a December 2015 VA examination of the Veteran's hands and peripheral nerves found that the Veteran's disability resulted in functional impact upon his ability to perform occupational tasks, including pain, numbness, and tingling sensations in the hands, which caused functional loss in holding, gripping, repetitive use, and fine manipulation, which was manifested by weakness, fatigue, and reduced endurance. Similarly, a subsequent January 2018 VA CTS examination revealed functional impact upon his ability to work in that the Veteran had problems with any repetitive use of the hands/upper extremities. While the Board acknowledges such findings and the resulting impairment identified by the VA examiners, the Board notes that neither the December 2015 or January 2018 VA examiners concluded that the Veteran's bilateral CTS resulted in an inability to secure or follow a substantially gainful occupation based upon such impairment. Finally, regarding the Veteran's service-connected hearing loss and tinnitus, the Board notes that a December 2014 VA audiology examination revealed functional impact due to the Veteran's hearing loss including the Veteran's report of great difficulties understanding conversational speech in noise and at distance without visual cues, without any resulting functional impact documented as a result of his tinnitus specifically. Notably, the Veteran's impaired hearing in noise and at a distance presents some functional impairment regarding his ability to secure and maintain a substantially gainful occupation; however, the Board cannot equate the Veteran's lay report regarding his hearing difficulty with an inability to secure or follow a substantially gainful occupation. The Veteran has consistently asserted throughout the appeal period that his service-connected disabilities preclude his ability to secure and follow a substantially gainful occupation. During the January 2019 Board hearing, the Veteran testified that he was fired on two previous occasions: first, in 1981 after he threatened to throw his boss through a window, and again in 2008 after he lost control of his emotions and raised his voice. Notably, these are apparent manifestations of the Veteran's service-connected PTSD, which is addressed specifically in the remand section below; however, the Board does not find that these two prior terminations indicate that the Veteran is unable to secure or follow a substantially gainful occupation due to all of his service-connected disabilities. Indeed, the Veteran's own reported occupational history, including over 20 years of experience as a manager/supervisor at the same company, indicates his ability to obtain more than an entry-level position based upon his educational history, including four years of high school and additional business management training and computer training. Moreover, the Board finds as fact that the Veteran's education and training in business and computers enables him with at least a minimum level of skills in order to secure and follow various substantially gainful occupations based upon his occupational history and education. To the extent that the June 2019 appellant's brief asserts that even if the Veteran could secure employment, it is highly unlikely that he would be able to maintain it, the Board find this to be purely speculative, and of limited probative value, especially when considered in light of the entire evidence of record. While the evidence of record documents some impairment resulting from all of the Veteran's service-connected disabilities, the evidence of record, as discussed in detail above, persuasively weighs against a finding that the Veteran's has been unable to secure or follow a substantially gainful occupation due to all of his service-connected disabilities for the entire period on appeal. In making this finding, the Board has considered (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, as discussed by the Court in Ray, 31 Vet. App. at 73. Regarding the Veteran's education, training, skills, and work history, his reported past occupational history includes over 20 years as a manager/supervisor. His educational history includes four years of high school and additional business management training and computer training. The Board finds as fact that the Veteran's job history as a manager and supervisor, and his educational and training experience, demonstrates a capacity for learning and adaptation that would facilitate the ability to perform substantially gainful employment, and indicates that the Veteran is enabled with at least a minimum level of skills in order to secure and follow various substantially gainful occupations based upon his occupational history and education. As to the Veteran's physical ability to perform substantially gainful employment, the Board acknowledges that the evidence of record, including as discussed above, documents some relevant functional impairment on his physical abilities. For example, the Veteran's service-connected CAD was found to result in symptoms of fatigue, dyspnea, and dizziness with strenuous activities. The Veteran's bilateral CTS was found to result in pain, numbness, and tingling sensations in the hands, which caused functional loss in holding, gripping, repetitive use, and fine manipulation, which was manifested by weakness, fatigue, and reduced endurance, as well as problems with any repetitive use of the hands/upper extremities. The Veteran's service-connected hearing loss was found to result in great difficulties understanding conversational speech in noise and at distance without visual cues. While the Board acknowledges such functional impairment on physical ability, the Board finds that the evidence does not persuasively weigh in favor of a finding that such impairment results in an inability to secure or follow a substantially gainful occupation for any period on appeal. As to the Veteran's ability to perform the mental requirements of substantially gainful employment, the Veteran has a 50 percent rating for PTSD, which contemplates functional impact resulting from this disability. The Veteran has reported a range of symptoms relating to his psychiatric disorder, including irritability and depression; however, the Veteran maintained strong family relationships with his spouse and son throughout the appeal period and has documented ongoing concern for his son's wellbeing and expressed sincere grief after his wife's death in 2016. Additionally, the Veteran's psychiatric symptoms have been shown to be accommodated by his prescribed use of a service animal, which is an accommodation that could be afforded by multiple types of employers and his past experience in business and management could lead to various occupations, including virtual positions that would require limited interaction with coworkers and the public, so as to limit excess stress and interpersonal conflict. However, as discussed below, the Board has remanded the matter is whether the Veteran is unable to secure or follow a substantially gainful occupation due solely to his PTSD. 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 prior job experience and employment history indicates that there are jobs that could be performed for which the Veteran is already qualified, including in business, management, and/or consulting. The Veteran's educational background, training, and employment history is probative evidence that he retains the physical and mental ability to perform activities required by such occupations, in spite of any physical or mental functional impairment resulting from all of his service-connected disabilities. Indeed, while the Veteran's physical impairments discussed above may limit his ability to performing occupations such as a warehouse worker, assembly line worker, or custodian, which are positions that would involve repetitive physical tasks, there is no probative indication that he would be unable to work at such positions without reasonable accommodations, including breaks and adapted procedures to maximize his physical ability. Moreover, given his education and employment history, the Board finds that the Veteran would be able to perform in a virtual consulting type of position that would have structure and would allow his use of a service animal without necessarily requiring significant social interaction or physical tasks. The Veteran would also be capable of performing occupations without significant physical or strenuous activities, such as ride-share driver for Lyft or Uber. These examples are not exhaustive but are merely illustrative of potential occupations that the Veteran could perform even in light of functional impairment resulting from all of his service-connected disabilities. This is evidence against a finding that the Veteran is unable to secure or follow all forms of substantially gainful occupation due to all of his service-connected disabilities. In sum, while the evidence documents some functional impact upon the Veteran's ability to work based upon all of his service-connected disabilities, the Board concludes that such functional impairment is adequately contemplated by the Veteran's combined disability rating throughout the appeal period. The Board concludes that, for all the reasons laid out above, the evidence is neither evenly balanced nor approximately so with regard to the Veteran's claim of entitlement to a TDIU rating due to all of his service-connected disabilities for the entire period on appeal. Rather, the evidence persuasively weighs against entitlement to a TDIU due to all of his service-connected disabilities for the entire period on appeal. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch, supra. As such, the claim for entitlement to a TDIU due to all of his service-connected disabilities is denied. REASONS FOR REMAND 5. Entitlement to referral for consideration of an extraschedular TDIU rating based solely on PTSD is remanded. As noted above, there are minimum disability rating percentages that must be shown for the service-connected disabilities, alone or in combination, to even qualify for consideration for a TDIU award under the schedular criteria. 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 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). Such claims shall be referred to the Director, Compensation and Pension Service, for consideration of an extraschedular TDIU rating. In a recent precedential decision, the Court held that, pursuant to Ray, supra, the proper standard for whether referral of an extraschedular TDIU claim to the Director, Compensation and Pension Service is warranted is "whether there's sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable because of service-connected disabilities." See Snider v. McDonough, 35 Vet. App. 1, 3 (2021). Here, the Board finds that referral to the Director, Compensation and Pension Service is warranted, as there is sufficient evidence to substantiate a reasonable possibility that the Veteran is unemployable because of his service-connected PTSD alone. As discussed above, a December 2015 VA examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity, while a November 2018 VA examiner identified 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. Although the February 2014 VA examiner concluded that the Veteran's psychiatric symptoms resulted in occupational and social impairment with deficiencies in most areas, this finding was found to be outweighed in its probative value, as discussed above, due to its inconsistency with additional evidence of record. Similarly, a December 2015 Vet Center counselor opined that the Veteran's PTSD symptoms had worsened to the point that he was unable to be gainfully employed and that he met the criteria for a TDIU rating, although the Board has discussed above how such conclusion is inconsistent with additional evidence discussed above. However, the Board has also considered the October 2021 private opinion of Dr. Cesta, who stated that it would not be feasible for the Veteran use his learned ability to manage his anger by avoiding any potentially triggers in a gainful employment setting, as "virtually any job requires the ability to cope with stress and interact routinely with coworkers, supervisors, and/or the public." Additionally, Dr. Cesta stated that the Veteran's coping mechanisms prevent him from meeting those basic requirements of gainful employment, thereby preventing him from functioning adequately in a workplace. Dr. Cesta stated that since leaving the workplace, the Veteran had become profoundly isolated and struggles with basic interpersonal interactions, which would prohibit him from returning to his past work as a supervisor in a book binding company, while his diminished cognitive functioning, impaired memory, and poor task completion would significantly limit the number and types of jobs available to him. Given the combination of these limitations, as well as his high school education, Dr. Cesta opined that the Veteran has been unable to function in a gainful occupation environment due to his PTSD since June 2008. Given the conflicting evidence above concerning the functional impairment on the Veteran's employability resulting from his service-connected PTSD specifically, the Board finds that, in light of Snider, there is sufficient evidence to substantiate a reasonable possibility that the Veteran is unemployable based solely on his service-connected PTSD. As such, remand is necessary to refer the claim to the Director, Compensation and Pension Service for extraschedular consideration. The matter is REMANDED for the following action: Refer the Veteran's claim of entitlement to an extraschedular TDIU rating based solely on PTSD to the Director, Compensation Service for extraschedular consideration pursuant to 38 C.F.R. § 4.16(b). A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Chad Johnson, 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.