Citation Nr: 0810681 Decision Date: 04/01/08 Archive Date: 04/14/08 DOCKET NO. 05-21 517 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently rated as 70 percent disabling. 2. Entitlement to special monthly compensation based on the need for aid and attendance. 3. Entitlement to a total rating based upon individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD John Kitlas, Counsel INTRODUCTION The veteran served on active duty from February 1951 to November 1952. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions promulgated in July 2004 and June 2006 by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. By the July 2004 rating decision the RO, in pertinent part, denied the veteran's TDIU claim. Thereafter, by the June 2006 rating decision, the RO denied the PTSD and special monthly compensation claims. The Board notes that the veteran's daughter has been appointed as his guardian/conservator. Consequently, in the adjudication that follows any reference to the veteran's contentions, unless specifically noted otherwise, will include those made by the veteran himself, as well as those made on his behalf by his daughter and attorney. FINDINGS OF FACT 1. All reasonable development and notification necessary for the equitable disposition of the instant case has been completed. 2. The veteran's service-connected PTSD is not manifested by 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. 3. In addition to his PTSD, the veteran is service-connected for bilateral hearing loss, evaluated as noncompensable (zero percent disabling); and tinnitus, evaluated as 10 percent disabling. The combined rating is 70 percent. 4. The veteran's service-connected disabilities have not resulted in the inability to dress and undress himself or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliance; inability of the claimant to feed himself through loss of coordination of the upper extremities or through extreme weakness; inability to tend to the wants of nature; or incapacity, physical or mental, which requires care and assistance on a regular basis to protect the veteran from the hazards or dangers incident to his daily environment. 5. The veteran has not been rendered unable to obtain and/or maintain substantially gainful employment due solely to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.130, Diagnostic Code 9411 (2007). 2. The criteria for special monthly compensation based on the need for aid and attendance are not met. 38 U.S.C.A. §§ 1114, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.350 (2007). 3. The criteria for the assignment of a TDIU are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.340, 4.16 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes at the outset that, in accord with the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The United States Court of Appeals for Veterans Claims (Court) has held that adequate notice, as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In this case, the Board observes the veteran was sent pre-adjudication notice regarding his TDIU claim by a letter dated in January 2004. He was also sent additional correspondence on that issue by a letter dated in August 2005. In regard to the PTSD and special monthly compensation claims, he was sent pre- adjudication notice by letters dated in January and March 2006. Moreover, he was sent further notification as to the special monthly compensation claim by a December 2006 letter. In pertinent part, the January 2004 and August 2005 letters summarized the criteria for establishment of a TDIU, while the December 2006 letter summarized the legal criteria for special monthly compensation based on the need for aid and attendance. Further, taken together, the aforementioned VCAA letters informed the veteran of the evidence necessary to substantiate his current appellate claims, what information and evidence he must submit, what information and evidence will be obtained by VA, and indicated the need for the veteran to advise VA of or to submit any evidence in his possession that was relevant to the case. As such, this correspondence fully complied with the notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), as well as the holding in Quartuccio, supra. Moreover, the March 2006 letter apprised the veteran of the specific information regarding disability rating(s) and effective date(s) outlined by the Court's holding in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board observes that the Court recently issued a decision in the case of Vazquez-Flores v. Peake, No. 05-0355 (U.S. Vet. App. January 30, 2008), regarding the information that must be provided to a claimant in the context of an increased rating claim. Specifically, the Court held that section § 5103(a) requires: (1) at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; and (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Vazquez-Flores, slip op. at 5-6. In regard to the aforementioned criteria, the Board notes that the January 2006 letter satisfies element (1), while the March 2006 letter satisfies element (3). Although none of the aforementioned notification letters contained the specific criteria of the relevant Diagnostic Code (i.e., element (2)), this information was included in the July 2006 Statement of the Case. The Board also notes that the veteran has actively participated in the processing of his case, and the statements submitted in support of his claim have indicated familiarity with the requirements for the benefits sought on appeal. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (VA can demonstrate that a notice defect is not prejudicial if it can be demonstrated ... that any defect in notice was cured by actual knowledge on the part of the appellant that certain evidence (i.e., the missing information or evidence needed to substantiate the claim) was required and that the appellant should have provided it.); see also Overton v. Nicholson, 20 Vet. App. 427 (2006). His familiarity with the pertinent criteria for a higher rating is further demonstrated by the fact that he has had prior claims for an increased rating since service connection was established. All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (harmless error). In view of the foregoing, the Board finds that the veteran was notified and aware of the evidence needed to substantiate his claims and the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. In addition, the duty to assist the veteran has been satisfied in this case. All available medical records pertinent to the issues on appeal are in the claims folder, to include records from the Social Security Administration (SSA). Nothing indicates that the veteran has identified the existence of any other relevant evidence that has not been obtained or requested. Further, he has had the opportunity to present evidence and argument in support of his claims. However, on all three of his Substantive Appeals he indicated that he did not desire a Board hearing in conjunction with his appeal. Moreover, he was accorded VA medical examinations in June 2004 and March 2006 regarding this case. Consequently, for these reasons, the Board concludes that VA has fulfilled the duty to assist the appellant in this case. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). In this, and in other cases, only independent medical evidence may be considered to support medical findings. The Board is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Here, nothing on file shows that the veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Consequently, his contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). I. PTSD Legal Criteria. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations applies, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, the Court recently held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). With regard to the veteran's request for an increased schedular evaluation, the Board will only consider the factors as enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). Diagnostic Code 9411 provides that PTSD is evaluated under the general rating formula used to rate psychiatric disabilities other than eating disorders. 38 C.F.R. § 4.130. When a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication, a noncompensable (zero percent) evaluation is warranted. Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication warrants a 10 percent evaluation. A 30 percent disability rating is in order when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent 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 rating 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; 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating 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; memory loss for names of close relatives, own occupation, or own name. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall 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. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). Analysis. In the instant case, the Board finds that the veteran does not meet or nearly approximate the criteria for a rating in excess of 70 percent for his service-connected PTSD during any portion of the appeal period. The veteran's service-connected PTSD is not manifested by total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The June 2004 VA examination found, in pertinent part, that the veteran's speech was of normal tone, volume, and pacing, with no pressure of speech. Further, it was noted that he was not threatening or angry during the examination, nor did he indicate bizarre or unusual behavior. Moreover, it was specifically stated that he was not a danger to himself or others; that he needed no help with activities of daily living; that he was oriented to person, place, and situation; and that his memory, both recent and remote, was intact. The Board acknowledges that the examiner found the veteran's thought process to have significant circumstantiality and tangential thinking. Nevertheless, he could reach goal idea, but often what appeared to be vague information, but in the end he could bring it together and show how it was connected. As such, this symptom appears to encompass circumstantial, circumlocutory, or stereotyped, speech, which, as noted above, is actually part of the criteria for a 50 percent rating under Diagnostic Code 9411. Therefore, it does not appear to be the type of gross impairment in thought processes or communication so as to warrant a 100 percent rating. In addition, the veteran's content of thought revealed no overt delusions, hallucination, or signs of grandiosity. The more recent March 2006 VA medical examination found the veteran's attitude to be cooperative, attentive; his attention was intact; his speech was spontaneous, clear, coherent; his thought process was goal directed and coherent; his thought content was unremarkable; he had no presence of suicidal or homicidal thoughts; he was found able to maintain minimum personal hygiene; and had no problems with activities of daily living. Although there was some evidence of memory impairment, his remote memory was found to be normal, his recent memory only mildly impaired, and his immediate memory was only moderately impaired. The Board acknowledges that the veteran was found to be disoriented to time, but this one symptom in and of itself does not support a 100 percent rating, particularly in light of the fact that none of the other requisite symptomatology and/or impairment is present. Further, the veteran was found to be oriented to person and place. The Board also acknowledges that the veteran's PTSD has resulted in occupational and social impairment. However, all compensable evaluations under the schedular criteria include such impairment. Therefore, the issue is whether the level of the veteran's occupational and social impairment is of such severity as to warrant a rating in excess of 70 percent. Of particular importance in evaluating the veteran's level of occupational and social impairment are the global assessment of functioning (GAF) scores he has been assigned, because such designations are based on a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). GAF scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e. g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). In this case, both the June 2004 and March 2006 VA medical examinations assigned a GAF score of 50, which, as noted above, indicates serious symptoms (or any serious impairment in social, occupational or school functioning. The examiner also stated that the PTSD had resulted in frequent impaired work, family, and other relationships. However, the examiner also specifically stated that such impairment was moderate. Further, the examiner stated that other conditions/diagnoses noted in the past included dementia, as well as delusions noted on prior evaluations, but that these disorders were a separate process from the PTSD. It is also noted that both examinations were conducted by the same examiner, who described the level of the veteran's occupational and social impairment on the June 2004 VA examination by terms consistent with the symptomatology for a 70 percent rating under Diagnostic Code 9411. For example, the examiner stated that the veteran's history indicated difficulty adapting to stressful circumstances which would include the work setting; that his history in the past indicated that he did not tolerate supervision and being bossed; and that he had difficulty establishing effective working relationships and responds more often by being confrontational. There were also references to impaired impulse control on the June 2004 examination. At the more recent March 2006 VA examination, the examiner stated that the veteran's PTSD symptoms were at the same level they were when evaluated in June 2004, and that the symptoms had been stable. The Board further observes that the examiner opined in May 2006 that the veteran's nonservice-connected dementia was the reason why the veteran needed aid and attendance, and that the PTSD did not cause him to need aid and attendance. In view of the foregoing, the competent medical evidence does not reflect the veteran's PTSD has resulted in total occupational and social impairment. Therefore, the preponderance of the evidence is against a rating in excess of 70 percent for PTSD. II. Special Monthly Compensation Legal Criteria. Special monthly compensation is payable to a person who is permanently bedridden or so helpless as a result of service-connected disability that he is in need of the regular aid and attendance of another person. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b). Determinations as to the need for aid and attendance must be based on actual requirements of personal assistance from others. In making such determinations, consideration is given to such conditions as: Inability of the claimant to dress and undress himself or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliance; inability of the claimant to feed himself through loss of coordination of the upper extremities or through extreme weakness; inability to tend to the wants of nature; or incapacity, physical or mental, which requires care and assistance on a regular basis to protect the claimant from the hazards or dangers incident to his daily environment. "Bedridden" will be a proper basis for the determination and is defined as that condition which, through its essential character, actually requires that the claimant remain in bed. It is not required that all of the disabling conditions enumerated above be found to exist before a favorable rating may be made. The particular personal functions which the claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the claimant is so helpless as to need regular aid and attendance, not that there be a constant need. 38 C.F.R. § 3.352(a). In addition, determinations that the appellant is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him to be in bed. They must be based on the actual requirement of personal assistance from others. See Prejean v. West, 13 Vet. App. 444 (2000); Turco v. Brown, 9 Vet. App. 222 (1996). Analysis. In the instant case, the Board finds that the veteran does not meet or nearly approximate the criteria for special monthly compensation based on the need for regular aid and attendance. In addition to his PTSD, the veteran is service connected for bilateral hearing loss, evaluated as noncompensable; and tinnitus, evaluated as 10 percent disabling. The record reflects the veteran's service-connected disabilities have not resulted in the inability to dress and undress himself or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliance; inability of the claimant to feed himself through loss of coordination of the upper extremities or through extreme weakness; inability to tend to the wants of nature; or incapacity, physical or mental, which requires care and assistance on a regular basis to protect the veteran from the hazards or dangers incident to his daily environment. As noted above, both the June 2004 and March 2006 VA medical examinations indicated the veteran's PTSD did not prevent him from completing activities of daily living. The March 2006 examination also found that he was able to maintain minimum personal hygiene. There is no indication that the service-connected hearing loss and tinnitus, either separately or together, causes such impairment. Moreover, nothing in the record indicates any he had special prosthetic or orthopedic appliance, nor impairment of the upper extremities, due to the service-connected disabilities. The record does reflect that the veteran was hospitalized for inpatient care in 2006, and that diagnoses were PTSD and dementia. However, as already noted, the VA examiner opined in May 2006 that the veteran's nonservice-connected dementia was the reason why the veteran needed aid and attendance, and that the PTSD did not cause him to need aid and attendance. In short, there is competent medical evidence on file which enables the Board to differentiate between symptomatology attributed to the nonservice-connected dementia and the service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). No competent medical evidence is of record which refutes this May 2006 VA medical opinion. In view of the foregoing, the Board finds that the preponderance of the evidence is against the veteran's claim of entitlement to special monthly compensation based on the need for aid and attendance. III. TDIU Legal Criteria. It is the established policy of the VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). A total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. A total disability may or may not be permanent. Total ratings will not be assigned, generally, for temporary exacerbations or acute infectious diseases except where specifically prescribed by the schedule. 38 C.F.R. § 3.340(a). A total disability rating for compensation purposes may be assigned where the schedular rating is less than total, where it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, providing at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 4.16(a). In determining whether the veteran is entitled to a total disability rating based upon individual unemployability, neither his nonservice-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Id. Analysis. In the instant case, the Board finds that the veteran is not entitled to a TDIU. As already noted, the veteran is service-connected for PTSD, evaluated as 70 percent disabling; hearing loss, evaluated as noncompensable; and tinnitus, evaluated as 10 percent disabling. Therefore, he has a combined disability rating of 70 percent. See 38 C.F.R. § 4.25. In short, he satisfies the requirements for consideration of a TDIU on a schedular basis. Despite the foregoing, the medical and other evidence of record does not reflect that the veteran is unable to obtain and/or maintain substantially gainful employment due solely to his service-connected disabilities. For the reasons detailed above, the Board has determined that the veteran's PTSD has not resulted in total occupational impairment. The medical evidence regarding the hearing loss and tinnitus do not indicate they cause such impairment, even when combined with the service-connected PTSD. The Board further finds that there is no competent medical evidence of record which reflects that the veteran is unable to obtain and/or maintain substantially gainful employment due solely to his service-connected disabilities. Moreover, the record reflects that he experiences significant impairment due to nonservice-connected disabilities. For example, the SSA records indicate that disability benefits were awarded primarily due to the impairment caused by atherosclerotic cardiovascular disease, status-post double coronary artery bypass. Although there was a secondary diagnosis of anxiety neurosis, the records reflect that the primary disability was the aforementioned heart disorder, and service connection has been denied for such a disability. In addition, as detailed above, there is competent medical evidence to the effect that he requires aid and attendance due to nonservice-connected dementia, which is a separate and distinct disability from his service-connected PTSD. In view of the foregoing, the Board finds that the preponderance of the evidence is against the veteran's claim of entitlement to a TDIU. IV. Conclusion For the reasons stated above, the Board finds that the preponderance of the evidence is against the veteran's current appellate claims, and the benefits sought on appeal must be denied. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application in the instant case. See generally Gilbert, supra; see also Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). ORDER Entitlement to an increased rating for PTSD, currently rated as 70 percent disabling, is denied. Entitlement to special monthly compensation based on the need for aid and attendance is denied. Entitlement to a TDIU due to service-connected disabilities is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs