POSTTRAUMATIC STRESS DISORDER (PTSD)

APRIL MADDOX · 2024 · Case ID: 24033045

MIXED

Summary

The veteran, who served with multiple periods of service between June 1968 and October 1984, including service in Vietnam, appeals the denial of an increased rating for PTSD with substance abuse and the failure to adjudicate entitlement to Special Monthly Compensation (SMC) at the housebound rate. The Board previously denied an increased rating for PTSD, but a Joint Motion for Remand (JMR) from the Court of Appeals for Veterans Claims vacated this denial, citing the Board's failure to adequately discuss a private psychological evaluation and address the reasonably raised theory of entitlement to SMC. The veteran's PTSD symptoms, as described by VA examiners and a private psychologist, include chronic sleep disturbance, nightmares, agitation, paranoia, avoidance of triggers, flashbacks, persistent negative beliefs, impaired impulse control, and suicidal ideation. While VA examiners found occupational and social impairment with deficiencies in most areas, consistent with a 70% rating, a private examiner opined that the veteran's PTSD and depression totally affected his ability to function in any competitive situation. The Board found the VA examiners' opinions more probative, concluding that the veteran's PTSD did not result in total occupational and social impairment, despite acknowledging serious symptoms like suicidal ideation. The Board found the veteran's reported social interactions, however limited, and ability to manage his household weighed against total impairment. The Board granted SMC at the housebound rate effective January 11, 2022, finding the veteran's PTSD alone rendered him unable to secure or maintain substantially gainful employment and that he met the criteria for a 60% combined disability rating from that date.

Rationale

Weight of probative evidence against total impairment; VA examiners' opinions found more probative; Limited social interactions and household management weigh against total impairment

Special Benefit

SMC - HOUSEBOUND

Docket No.

19-02 045

Full Decision Text

Citation Nr: 24033045
Decision Date: 11/14/24 Archive Date: 11/14/24

DOCKET NO. 19-02 045
DATE: November 14, 2024

ORDER

A disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD), with substance abuse, for the period on appeal beginning November 15, 2018, is denied.

Special monthly compensation (SMC) at the statutory housebound rate specified at 38 U.S.C. § 1114 (s), from June 17, 2022, is granted, subject to the laws and regulations governing the award of monetary benefits.

FINDINGS OF FACT

1. During the period on appeal beginning November 15, 2018, the Veteran's PTSD with substance abuse has been manifested by no worse than occupational and social impairment with deficiencies in most areas; the Veteran's acquired psychiatric disorder has not resulted in total occupational and social impairment.

2. The Veteran's PTSD, alone, has been shown to render him unable to sustain substantially gainful employment and he has additional disabilities rated at 60 percent or more, from June 17, 2022.

CONCLUSIONS OF LAW

1. For the period on appeal beginning November 15, 2018, the criteria for an evaluation in excess of 70 percent for PTSD with substance abuse have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102,?4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411.

2. The criteria for SMC at the housebound rate, from June 17, 2022, have been met. 38 U.S.C. § 1114, 38 U.S.C. § 7104; 38 C.F.R. § 3.351 (d), 38 C.F.R. § 20.101.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1968 to May 1971, from July 1972 to July 1978, and June 1982 to October 1984. On January 11, 2022, the Veteran testified at a Board hearing before the undersigned Acting Veterans Law Judge (AVLJ). A complete transcript of the hearing is associated with the record.

This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decision issued in January 2019 by a Department of Veterans Affairs (VA) Regional Office (RO).

This appeal was previously before the Board in April 2023. The Board decision awarded a 20 percent rating for bladder cancer, from December 10, 2019, to January 11, 2022; a 40 percent rating for bladder cancer, from January 11, 2022, to May 13, 2022; a total disability rating based on individual unemployability (TDIU), from October 1, 2018; and an effective date of October 1, 2018, for the basic eligibility to Dependents' Educational Assistance (DEA). The Board also denied: a rating in excess of 70 percent for PTSD, with substance abuse, from November 15, 2018; a rating in excess of 10 percent for bladder cancer, from October 1, 2018 to December 10, 2019; a rating in excess of 20 percent for bladder cancer from December 10, 2019 to January 11, 2022; a rating in excess of 40 percent for bladder cancer, from January 11, 2022 to May 13, 2022; a rating in excess of 60 percent for bladder cancer, from May 13, 2022; an effective date prior to basic eligibility to DEA; a TDIU, prior to October 1, 2018, and beginning May 13, 2019; and a compensable rating for erectile dysfunction, from February 1, 2018.

The Veteran appealed the decision the United States Court of Appeals for Veterans Claims (Court), with respect to the denial of the rating in excess of 70 percent for PTSD, from November 15, 2018; and the failure to adjudicate the issue of entitlement to SMC. The Court granted a Joint Motion for Remand (JMR), in January 2024, vacating the Board's decision with respect to the increased rating for PTSD, and remanding the matter consistent with the concerns raised by the JMR.

The JMR noted that the Board
1, 2018, and beginning May 13, 2019; and a compensable rating for erectile dysfunction, from February 1, 2018.

The JMR noted that the Board failed to provide an adequate statement of reasons or bases, when it failed to adequately discuss a September 2020 private psychological evaluation report. The JMR also noted that the September 2020 examiner noted that the Veteran's PTSD symptoms, alone, may have precluded him from substantially gainful employment, and that the Board failed to address whether the Veteran could have established entitlement to SMC, under 38 U.S.C. § 1114 (s). As such, the parties agreed that the Board failed to provide an adequate statement of reasons or bases because of its failure to address the reasonably raised theory of entitlement to SMC; and that the Board must address whether the Veteran was entitled to SMC, based on a single service-connected disability, rated as total, consistent with 38 U.S.C. § 1114 (s). See Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2010).

Increased Rating

1. PTSD with Substance Abuse

The Veteran contends that he is entitled to increased ratings for PTSD with substance abuse.

By way of history, in a June 2011 rating decision, the RO awarded the Veteran service connection for PTSD with substance abuse with a 50 percent evaluation under 38C.F.R. §4.130, Diagnostic Code 9411, effective June 23, 2010. The 50 percent rating was continued in a February 2013 rating decision. In an August 2016 rating decision, the RO awarded the Veteran an increased rating of 70 percent for PTSD, effective April 20, 2016. The Veteran timely appealed with a notice of disagreement (NOD) in November 2016. However, after an August 2017 statement of the case (SOC) that again denied the claim of increased ratings for PTSD, the Veteran did not timely file a VA Form 9 to appeal the decision.

The Veteran filed the current claim for an increased rating for PTSD with substance abuse on November 15, 2018. The RO denied the Veteran's claim in the January 2019 rating decision currently at issue. The Veteran timely appealed.

The Board notes that the current appeal period for the issue of increased ratings for PTSD with substance abuse begins on November 15, 2018, the date VA received the Veteran's claim that led to the January 2019 rating decision currently at issue, plus a one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The 70 percent evaluation for PTSD with substance abuse applies to the entire period currently on appeal.

As discussed, the Veteran appealed this issue to the Court, where a JMR was issued. However, the JMR did not specifically discuss any concerns related to the increased rating claim for PTSD. The JMR discussed that the Board failed to adequately discuss the September 2020 psychological evaluation, with respect to whether the Veteran was capable of performing substantially gainful employment, due solely to psychiatric symptoms. While the JMR did not appear to raise any specific concerns with respect to the increased rating claim for PTSD, the Board nonetheless recognizes that the JMR vacated the Board's denial of a rating in excess of 70 percent for PTSD, and will proceed with readjudication of the issue.

Diagnostic Code 9411 provides that an acquired psychiatric disorder should be evaluated pursuant to the General Rating Formula for Mental Disorders (General Formula). 38 C.F.R. § 4.130. Under the General Formula, a 70 percent evaluation is warranted 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance
9411 provides that an acquired psychiatric disorder should be evaluated pursuant to the General Rating Formula for Mental Disorders (General Formula). 38 C.F.R. § 4.130. Under the General Formula, a 70 percent evaluation is warranted 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id.

A 100 percent evaluation is warranted where 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; or memory loss for names of close relatives, own occupation, or own name. Id.

As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18 ; 38 C.F.R. § 4.130, DC 9413.

Furthermore, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126 (a).

In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the general rating formula "indicates that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas." However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment.

In a January 2019 statement, a friend of the Veteran, DC, stated that he had known the Veteran for 10 years, and the Veteran had been a guest in his home for BBQs and beers numerous times. DC recalled that, one night after a few beers, the Veteran became very agitated, acting very strange. He became paranoid and wanted to fight. DC stated that, when the Veteran was agitated, it seemed like he went back in time, perhaps with a flashback from Vietnam. The Veteran yelled, "Get the fuck away from me." DC and his wife eventually calmed him down. He laid on the couch, and in time, he fell asleep. DC noticed that the Veteran's breathing became very shallow; and at times, DC could not tell if he was breathing at all. DC stayed up all night monitoring the Veteran's breathing. When the Veteran awoke in the morning, he did not remember anything. DC said the incident was very disturbing. DC stated that, for the most part, the Veteran is a very kind, giving person, but there is something very disturbing "pinned up in his conscience."

In an October 2021 statement, the Veteran stated that, between October 1, 2018, and May 13
DC and his wife eventually calmed him down. He laid on the couch, and in time, he fell asleep. DC noticed that the Veteran's breathing became very shallow; and at times, DC could not tell if he was breathing at all. DC stayed up all night monitoring the Veteran's breathing. When the Veteran awoke in the morning, he did not remember anything. DC said the incident was very disturbing. DC stated that, for the most part, the Veteran is a very kind, giving person, but there is something very disturbing "pinned up in his conscience."

In an October 2021 statement, the Veteran stated that, between October 1, 2018, and May 13, 2019, due to his PTSD, he could not deal with people, and he could not leave the house. He was constantly depressed, and this caused him to lose a massive amount of weight. His conditions continued to worsen to where he was physically not able to function, and he was not able to work. He lacked energy and had constant depression. He stated that his conditions continue to worsen, and he will never be able to work again in his life.

At the January 2022 Board hearing, the Veteran reported that he experiences anxiety attacks and gets very little sleep. He stated that he used to do a lot of drinking, but he stopped drinking because of his cancer. He described an incident where he was at a friend's house when he stopped breathing, and they stayed up with him all night. He stated that he stays away from people because he does not trust them. He stated that he has seen what people really are in an uncontrolled environment, such as a war. He stated that this is what set him off because he saw the true nature of people come out. He stated that he feels safer at home.

The Veteran stated that, if he went out with other people, he would experience anxiety attacks frequently. If he was by himself and he did not have to deal with people, he could pretty much control what he thinks. He stated that he does not go to the grocery store or drug store, and he has his groceries delivered. The only time he leaves the house is when he has to go to the doctor for treatment or surgery. Other than that, he does not go anywhere, and he does not want to go anywhere.

The Veteran further stated that he had one friend that he talked to every morning over the phone, but he did not have other friends. He noted that he does not socialize with his friend in person, and his friend was a Vietnam veteran. The Veteran had four children and 10 or 12 grandchildren, but he did not talk to any of them. He stated that, when he came back from active service, he was attacked by his own family (particularly aunts and uncles) who were "not pro-American". He noted that his grandfather served in World War I, and his father served in World War II; and he felt it was his duty to serve.

Additionally, the Veteran stated that, when he is home alone during the day, he does not shower or take care of his personal needs. He stated that, when he showers, it lowers his body temperature, and he ends up sneezing all the time. He also does not get dressed or put on clean clothes every day. He noted that he was wearing the same clothes he had on for a week. He stated that nobody comes to see him, so he can do what he wants.

At a December 2018 VA examination, the VA examiner diagnosed the Veteran with PTSD and alcohol use disorder in sustained remission. The VA examiner that the Veteran's symptoms attributable to PTSD included chronic sleep disturbance, nightmares, agitation, short temper, intrusive memories of trauma exposure, avoidance of triggers related to memories of trauma, flashbacks, persistent negative beliefs about himself, others or the world, self-blame, negative emotional state, diminished interest, panic attacks, hypervigilance, exaggerated startle response, poor concentration with related memory problems, estrangement, and anxiety. The symptoms attributable to alcohol use disorder (in sustained remission) included prior excessive use of alcohol despite negative consequences with more than one year sobriety. The Veteran had previously used alcohol to avoid memories of trauma and to manage anxiety and depression related to these memories. The VA examiner found that, due to the Veteran's PTSD, he had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.

The VA examiner found symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events),
poor concentration with related memory problems, estrangement, and anxiety. The symptoms attributable to alcohol use disorder (in sustained remission) included prior excessive use of alcohol despite negative consequences with more than one year sobriety. The Veteran had previously used alcohol to avoid memories of trauma and to manage anxiety and depression related to these memories. The VA examiner found that, due to the Veteran's PTSD, he had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.

The VA examiner found symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), impairment of short and long term memory (for example, retention of only highly learned material, while forgetting to complete tasks), flattened affect, disturbances of motivation and mood, inability to establish and maintain effective relationships, suicidal ideation, and impaired impulse control (such as unprovoked irritability with periods of violence).

The VA examiner observed that the Veteran's dress was appropriate, but his clothes were somewhat unclean. He was deemed to be a reliable informant due to clear cognition, non-defensive response to questions, and a report of information without evidence of manipulation or exaggeration. His thought process was logical and goal-directed, and he was able to track the conversation during the interview and provide a coherent history. His judgment and insight were intact, and his speech pattern was within normal limits. He was able to make and maintain good eye contact. His mood was anxious, and his affect was agitated; and he became more agitated and tearful when discussing his trauma exposure history. He expressed passive suicidal ideation. There was no evidence of homicidal ideation or audio or visual hallucinations, and there was no evidence of a thought disorder. He was capable of managing his financial affairs.

At the time of the December 2018 VA examination, the Veteran had been in a relationship with a girlfriend for about three years, but he described the relationship as "not good" because he was more depressed. He was more socially withdrawn, and his self-esteem was diminished. The Veteran and his girlfriend were becoming too distant due to the intimacy problems. He was not able to talk about it with her, and he did not want her to have to learn or understand his problems. He believed the relationship would not survive much longer. The Veteran was living by himself, and he stated that he felt secure in his own home. He kept his home secure with a security system, and he had a dog. He noted that another of his dogs died six or seven months ago, which made him cry. The Veteran reported there were no other friends or visitors to the house. He reported that he talks with a friend named Bob every day, and Bob was also a Vietnam veteran. The Veteran had sisters, but he had no contact with them since 1993 or 1994 when his mother passed away. He stated that he did not want or need people in his life. The Veteran previously worked as a mechanic in his own shop (for 19 years), but he had not worked since 2011. He felt that he had to stop working due to his intolerance of people.

The Veteran reported that he was not sleeping at all except right after taking Hydrocodone. He had gone through cancer treatments since his last review, including surgeries on his bladder and prostate; and he continued to have pain associated with the surgeries. The Veteran reported having combat-related nightmares whenever he had a bad day with intrusive memoires. He would wake up feeling as if he was in Vietnam and was trying to get home. He described a recent nightmare where he was trying to get a pilot out of a burning plane in 1975. The Veteran's short-term memory was "really bad", but his long-term memory was good. He reported having intrusive memories of Vietnam when he smelled certain things or heard things. He was jumpy and vigilant, and he had panic attacks on a weekly basis. He did not trust people in general, and he felt better off without them. He felt depressed every day. The Veteran stated that, after the prostate surgery, he felt that he had been "half a man". He was taking Viagra to improve erectile functioning, and he could not be sexually active as frequently as in the past. His appetite was good, and he had more energy since having the prostate removal. At the time of the December 2018 VA examination, the Veteran had not been in mental health treatment since 2013, and he was not taking medication for sleep or mood. He stated that he attempted suicide over 30 years ago, and he recalled how he affected too many people.
basis. He did not trust people in general, and he felt better off without them. He felt depressed every day. The Veteran stated that, after the prostate surgery, he felt that he had been "half a man". He was taking Viagra to improve erectile functioning, and he could not be sexually active as frequently as in the past. His appetite was good, and he had more energy since having the prostate removal. At the time of the December 2018 VA examination, the Veteran had not been in mental health treatment since 2013, and he was not taking medication for sleep or mood. He stated that he attempted suicide over 30 years ago, and he recalled how he affected too many people. He did not have a plan to attempt suicide again. The December 2018 VA examiner found that the Veteran did not appear to pose a threat of danger or injury to himself or others.

The Veteran had a history of alcohol dependence. He reported abstinence for one or two years. He described an incident where he tried a shot of alcohol and was frightened because he stopped breathing for a while. He stopped drinking and did not miss it.

In a March 2019 VA Mental Health Initial Evaluation Note, the Veteran stated that he did not feel he could trust people, and he did not want to be around people. He stated that he had only one friend whom he could call and not feel like he was being judged. He reported that he lived alone, and he did not communicate with his kids because they did not understand him. He also stated that he felt he did wrong by going to Vietnam because he felt that he was looked down for loving his country. He reported that he stopped drinking a year and a half ago because he once stopped breathing when drinking and taking hydrocodone, and he felt embarrassed that his friend had to take care of him. He reported he still had cravings. Related to his PTSD, he still felt hypervigilance and an inability to trust people. He was unable to quantify how often nightmares, flashbacks, and intrusive memories bothered him. He reported that he would become anxious at times for no reason. He stated that, since he quit drinking, he no longer felt worthless. He denied having hallucinations or current suicidal or homicidal thoughts. The Veteran acknowledged that suicide would not fix anything.

The examiner observed that the Veteran was alert, attentive, cooperative, reasonable, and somewhat guarded. The Veteran's speech was slow with increased latency of response, but his language was intact. His mood was euthymic; and his affect was blunted, restricted, and constricted. There was no perceptual disturbance; and his thought process was linear, goal-directed, and logical. He had some impaired remote memory, but his insight and judgment were good.

At a May 2019 VA examination, the VA examiner diagnosed the Veteran with PTSD and alcohol use disorder. The Veteran's PTSD was characterized by exposure to a traumatic event, intrusive dreams and memories related to the trauma, avoidance of reminders symbolic of the trauma, and heightened arousal. His alcohol use disorder was characterized by the maladaptive use of alcohol which impacted important areas of life functioning. The alcohol use disorder was secondary to the PTSD and served as a form of self-medication. The Veteran had been reportedly sober for three or four years, but he had recently relapsed. The VA examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. At the time of the May 2019 VA examination, he was not receiving mental health treatment.

The VA examiner found that the Veteran had symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), impairment of short and long term memory (for example, retention of only highly learned material, while forgetting to complete tasks), flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control (such as unprovoked irritability with periods of violence), and neglect of personal appearance and hygiene.

The VA examiner observed that the Veteran's grooming and hygiene were poor. His motor activity was calm, and he maintained eye contact throughout the interview. His speech was unimpaired. He reported that he had impairment in his long- and short-term memory. His mood was anxious, and his affect was congruent. He was oriented; and there were no perceptual, thought process or thought content issues. He reported that he had past suicidal ideation, but he denied current intent. He denied any homicidal ideation. The May 2019 VA examiner found that the Veteran did not
impaired impulse control (such as unprovoked irritability with periods of violence), and neglect of personal appearance and hygiene.

The VA examiner observed that the Veteran's grooming and hygiene were poor. His motor activity was calm, and he maintained eye contact throughout the interview. His speech was unimpaired. He reported that he had impairment in his long- and short-term memory. His mood was anxious, and his affect was congruent. He was oriented; and there were no perceptual, thought process or thought content issues. He reported that he had past suicidal ideation, but he denied current intent. He denied any homicidal ideation. The May 2019 VA examiner found that the Veteran did not appear to pose a threat of danger or injury to himself or others.

The Veteran reported that he had a positive relationship with his parents and siblings. He had been married four times, but he was separated at the time of this examination. He had four children. His relationship with one of his children was positive, but he was distant with the others.

The Veteran reported that, after discharge from active service, he was more wary of other people, and he felt others were selfish and self-centered. The Veteran that he retired from work as a mechanic in 2011, and he stopped working due to too much stress, as well as due to his alcohol abuse. The Veteran stated that he had been self employed as a mechanic for much of his life. He stated that he had always worked by himself due to his inability to get along with others and work in a cooperative manner. He was impulsive and had a history of unprovoked irritability with periods of violence. His alcohol abuse and his mood instability (due to his PTSD) impacted his reliability, productivity and ability to function in the workplace. He lacked motivation and was excessively anxious when in public. He had episodes where he had panic attacks that impeded his ability to function occupationally and socially.

In a September 2020 private psychological evaluation, the Veteran reported that, following his discharge from the military, he began working as a long-haul trucker. He was drinking heavily and away from home for 13 weeks at a time. His drinking and isolated type career path created havoc within his marriage and family. He subsequently divorced and remarried several times. He had strained relationships with his four children, and he was in contact with only one of his children. He reported that he had attempted suicide on three occasions because of his self-described survivor's guilt.

The Veteran last worked in 2012 when he was self-employed as a mechanic. He had a small storefront business, but he was unable to continue because he could not interact with the public and sustain his business. He reported that his alcohol abuse continued until four or five years ago.

The Veteran stated that he tried to obtain treatment from VA for his psychological problems and substance abuse. However, his suspiciousness and guarded behavior resulted in poor outcomes. On one occasion, he terminated treatment with a VA psychiatrist when the doctor began inquiring about his possession of weapons. At the time of the September 2020 psychological evaluation, the Veteran was not in any form of mental health treatment. He expressed helplessness and hopelessness because he believed he had limited time left on earth. He spent time at home with his two dogs, which he believed protected him from undisclosed dangers. He lived alone in his own home. He was reportedly self-sufficient, and he cared for his own needs. He had only one friend, and he was estranged from family.

The private examiner found that the Veteran was adequately groomed and dressed appropriately, and he appeared his chronological age. He was generally cooperative, but he was obviously irritable and suspicious of the interview. His mental status was generally uncompromised. He was alert, well oriented, logical, coherent, and able to coherently communicate his needs despite his hearing difficulties, which made communication difficult at times. He did not report any psychotic experiences, and he did not report any present suicidal ideation. However, the examiner opined that the Veteran's present nihilistic thinking and lack of optimism for the future suggested a continued suicide risk. The Veteran slept poorly and experienced nightmares and intrusive memories on a regular basis. Counting and calculations were slow. The Veteran's attention and concentration and short- and long-term memory were mildly impaired. His mood was poor, and he was socially isolated and anhedonic. He denied current problems with alcohol. His intelligence appeared to be within the average range. The private examiner stated that the Veteran's insight and judgment were impaired, as evidence by his failed relationships and inability to interact with others.

The Veteran had a depressed mood nearly every day, and he had
ideation. However, the examiner opined that the Veteran's present nihilistic thinking and lack of optimism for the future suggested a continued suicide risk. The Veteran slept poorly and experienced nightmares and intrusive memories on a regular basis. Counting and calculations were slow. The Veteran's attention and concentration and short- and long-term memory were mildly impaired. His mood was poor, and he was socially isolated and anhedonic. He denied current problems with alcohol. His intelligence appeared to be within the average range. The private examiner stated that the Veteran's insight and judgment were impaired, as evidence by his failed relationships and inability to interact with others.

The Veteran had a depressed mood nearly every day, and he had markedly diminished interest or pleasure in all or most all activities. He had a decrease in appetite, daily insomnia, slowed activity, loss of energy, feelings of worthlessness or inappropriate guilt, and impaired concentration, as well as recurrent thoughts of death or suicidal ideation.

The Veteran stated that he was unable to work as early as 2012 when he lost his career as a self-employed mechanic. The private examiner observed that the medical records detailed the collapse of four marriages and three suicidal attempts during the 1980s while the Veteran abused alcohol to self-treat his psychological disorder.

The private examiner opined that the Veteran's PTSD and depression were totally affecting his ability to function in any competitive situation. The private examiner found that the Veteran demonstrated occupational and social impairment with deficiencies in most area, such as work (attention, concentration), social relations, and enjoyment of life. The private examiner stated that these psychological difficulties were solely responsible for the Veteran's difficulties in performing occupational duties.

The private examiner found that the Veteran had deficiencies in family relations, deficiencies in mood, persistent irrational fears, difficulty in adapting to stressful circumstances, intrusive recollections of a traumatic experience, grossly inappropriate behavior, persistent danger of hurting self and others, deficiencies in work or school, gross impairment in thought processes or communication, difficulty in adapting to stressful circumstances, unprovoked hostility and irritability, inability to establish and maintain effective relationships, deficiencies in judgment, suicidal ideation, and depression affecting ability to function independently, appropriately, or effectively.

The private examiner further found that the Veteran had markedly limited ability to remember locations and work-like procedures, maintain attention and concentration for extended periods, perform activities within a schedule, maintain regular attendance, be punctual within customary tolerance, sustain ordinary routine without supervision, work in coordination with or proximity to others without being distracted by them, complete a normal work week without interruptions from psychologically based symptoms, perform at a consistent pace without an unreasonable number and length of rest periods, interact appropriately with the general public, accept instructions and respond appropriately to criticism from supervisors, get along with coworkers or peers without distracting them or exhibiting behavioral extremes, maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness, respond appropriately to changes in the work setting, be aware of normal hazards and take appropriate precautions, or set realistic goals or make plans independently. He also had moderately limited ability to travel to unfamiliar places or use public transportation.

Here, the Board has heard the concerns raised by the JMR. However, based on the evidence of record described above, the Board finds that the symptoms associated with the Veteran's PTSD with substance abuse are best characterized as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, which is consistent with a 70 percent rating. The Board recognizes that the Veteran has reported and been found to have significant psychiatric symptoms, by the mental health professionals who have examined him, during the period on appeal. However, the Board finds that the Veteran's PTSD has not resulted in total occupational and social impairment, at any time. The Board acknowledges that the private September 2020 examiner found that the Veteran had the following symptoms, typically associated with a 100 percent rating, grossly inappropriate behavior, danger of hurting self or others, and gross impairment of thought processes or communication. The Board also recognizes that the Veteran was found to have symptoms not contained within the rating criteria, such as: feelings of worthlessness, feelings of self-blame, and persistent irrational fears. Further, the Veteran was also shown to have suicidal ideation during the period on appeal, which is a very serious symptom. While recognizing such a serious symptom, the Board does note that he has not had a suicide attempt since the 1980s; and he has not demonstrated an active plan or intent to commit suicide during the period on appeal since November 15, 2018.

While the Board acknowledges the Veteran's significant symptomatology, the Board also notes that the Veteran has reported that he maintains a close relationship with a fellow Vietnam veteran, who he talks to on the phone every day. He also reported that he was in
such as: feelings of worthlessness, feelings of self-blame, and persistent irrational fears. Further, the Veteran was also shown to have suicidal ideation during the period on appeal, which is a very serious symptom. While recognizing such a serious symptom, the Board does note that he has not had a suicide attempt since the 1980s; and he has not demonstrated an active plan or intent to commit suicide during the period on appeal since November 15, 2018.

While the Board acknowledges the Veteran's significant symptomatology, the Board also notes that the Veteran has reported that he maintains a close relationship with a fellow Vietnam veteran, who he talks to on the phone every day. He also reported that he was in contact with one of his children at the September 2020 private examination. The evidence of record has also shown that the Veteran has lived alone and been able to maintain his household. He reported that he did not like to go to the grocery or drugstore and had his groceries delivered. The Board finds that this evidence persuasively is against a finding that the Veteran has total occupational and total social impairment, due to PTSD.

The Board acknowledges the Veteran's assertions that his PTSD with substance abuse is of a sufficient severity so as to warrant a higher disability rating. However, the competent medical evidence offering specific determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. Thus, the Veteran's own assessment as to the severity of the symptoms and their relationship to the rating criteria are less probative than the opinions of medical practitioners who have specialized knowledge and skill in excess of him. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007).

Moreover, the Board finds the report of the December 2018 and May 2019 VA examiners to be the more probative evidence of record concerning whether the Veteran's PTSD with substance abuse is severe enough to warrant a higher disability rating. The VA examiners' rationales are logical and well-reasoned and based on consideration of the Veteran's claims file, medical records, and post-service history. Thus, the Board is satisfied that the December 2018 and May 2019 VA examiners' opinions are competent, credible, persuasive, and probative for deciding this appeal.

The Board has also considered whether staged ratings under Hart, supra, are appropriate for the Veteran's acquired psychiatric disorder; however, the Board finds that, his symptomatology was stable throughout the appeal period for purposes of increased ratings for psychiatric disorders under VA regulations. Therefore, assigning staged ratings is not warranted in this case.

The weight of the probative evidence is against the assignment of an evaluation in excess of 70 percent for the Veteran's PTSD with substance abuse. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the weight of the probative evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

2. SMC (s).

SMC at the housebound rate is payable if a Veteran has a single service-connected disability rated at 100 percent and has an additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). A TDIU rating based on a single disability is permitted to satisfy the statutory requirement of a 100 percent rating. Bradley v. Peake, 22 Vet. App. 280, 293 (2008). A claim for increased disability compensation may include the "inferred issue" of entitlement to SMC, even where the appellant has not expressly raised the issue of SMC. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991).

As discussed, the JMR directed the Board to consider whether the September 2020 private psychological examination report reasonably raised whether entitlement to SMC is warranted, based on a finding that the Veteran's PTSD symptoms, alone, may have precluded him from substantially gainful employment.

The September 2020 examiner reported that the Veteran's psychological difficulties, were solely responsible for his difficulties in performing occupational duties; and that the impairments
293 (2008). A claim for increased disability compensation may include the "inferred issue" of entitlement to SMC, even where the appellant has not expressly raised the issue of SMC. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991).

As discussed in the prior Board decision, service connection has been established for PTSD with substance abuse, bilateral hearing loss, tinnitus, a tremor disorder, ED, and bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer).

The prior Board decision found that for the period on appeal between October 1, 2018, and May 13, 2019, all of the Veteran's service-connected disabilities, to include PTSD with substance abuse, bilateral hearing loss, tinnitus, a tremor disorder, ED, and bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), precluded him from securing or following substantially gainful employment.

However, after a review of the evidence of record, to include the September 2020 private psychological examination report, the Board finds that the Veteran's PTSD, alone, renders him unable to secure or maintain substantially gainful employment. In this regard, the December 2018 VA examination report noted significant psychological symptoms; and the May 2019 VA examiner found that his PTSD symptoms impacted his reliability, productivity, and ability to function in the workplace. He was also found to have a lack of motivation and was excessively anxious when in public, and had episodes where he had panic attacks that impeded his ability to function occupationally and socially. Further, the September 2020 private examiner reported that the Veteran had a markedly limited ability to remember locations and work-like procedures, maintain attention and concentration for extended periods, perform activities within a schedule, maintain regular attendance, be punctual within customary tolerance, sustain ordinary routine without supervision, work in coordination with or proximity to others without being distracted by them, complete a normal work week without interruptions from psychologically based symptoms, perform at a consistent pace without an unreasonable number and length of rest periods, interact appropriately with the general public, accept instructions and respond appropriately to criticism from supervisors, get along with coworkers or peers without distracting them or exhibiting behavioral extremes, maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness, respond appropriately to changes in the work setting, be aware of normal hazards and take appropriate precautions, or set realistic goals or make plans independently. He also had moderately limited ability to travel to unfamiliar places or use public transportation.

Here, the Board has considered the Veteran's education, with one year of high school, and his work history as a mechanic in his own shop. The Board resolves reasonable doubt in the Veteran's favor, and finds that his PTSD symptoms, alone causes him the inability to secure and maintain substantially gainful employment. In this regard, the Board notes that his psychological symptoms would preclude him from running his own business, or otherwise work as a mechanic because he has been found to have a lack of motivation, was excessively anxious when in public, and had episodes where he had panic attacks that impeded his ability to function occupationally. The private examiner also reported that he had a markedly limited ability to remember work-like procedures, maintain attention and concentration for extended periods. Further, his PTSD symptoms were also found to preclude him from maintaining regular attendance, being punctual within customary tolerance, sustaining ordinary routine without supervision, working in coordination with or proximity to others without being distracted by them, completing a normal work week without interruptions, and interacting appropriately with the general public.

In consideration of the Veteran's psychiatric symptoms, alone, his education and background are not such that he would be able to secure and follow a substantially gainful occupation under the facts of this case. With regard to the disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, the Veteran meets such criteria on January 11, 2022; where he has a 40 percent rating for residuals of bladder cancer, a 20 percent rating for bilateral hearing loss, a 10 percent rating for tinnitus, and a 10 percent rating for tremor disorder. Prior to January 11, 2022, he does not have a
interruptions, and interacting appropriately with the general public.

In consideration of the Veteran's psychiatric symptoms, alone, his education and background are not such that he would be able to secure and follow a substantially gainful occupation under the facts of this case. With regard to the disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, the Veteran meets such criteria on January 11, 2022; where he has a 40 percent rating for residuals of bladder cancer, a 20 percent rating for bilateral hearing loss, a 10 percent rating for tinnitus, and a 10 percent rating for tremor disorder. Prior to January 11, 2022, he does not have a combined 60 percent rating, separate from the rating for PTSD. See 38 C.F.R. § 4.25. As such, the earliest date the Veteran has been shown to have independently disabilities, rated at 60 percent, is from January 11, 2022.

Based on the foregoing, SMC (s) is granted from January 11, 2022.

APRIL MADDOX

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board E. Fu, 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.

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