Citation Nr: 21068083 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 14-12 395 DATE: November 9, 2021 ORDER Entitlement to an increased rating of 70 percent for PTSD is granted. Entitlement to a total disability based on individual unemployability (TDIU) as of February 25, 2011 is granted. Entitlement to special monthly compensation (SMC) based on housebound status is granted. FINDINGS OF FACT 1. The Veteran's PTSD has consistently manifested in symptoms resulting in occupational and social impairment with deficiencies in most areas. 2. The evidence establishes that the Veteran is unable to secure and maintain substantially gainful employment as a result of his service-connected PTSD as of February 25, 2011. 3. The preponderance of the evidence establishes that the Veteran's PTSD substantially confines him to the home, rendering him housebound. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 70 percent, but no higher, for PTSD are been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a TDIU are met as of February 25, 2011, but no earlier. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 4.16. 3. The criteria for an award of SMC based on housebound status are met. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1967 to March 1971. These matters are on appeal to the Board of Veterans' Appeals (Board) from February 2011 and October 2012 rating decisions. A hearing was held by the undersigned Veterans Law Judge in May 2017. The increased rating for PTSD claim was remanded by the Board in December 2017 and June 2019. In June 2020, the Board denied the claim. Pursuant to a Joint Motion for Remand wherein the parties agreed the Board had failed to address favorable evidence, to include evidence of suicidal ideation, the Court of Appeals for Veterans Claims vacated the June 2020 decision and remanded the claim back to the Board. 1. Increased rating - PTSD The Veteran's service-connected PTSD is rated under DC 9411 as 50 percent disabling. He filed a non-initial increased rating claim that was received by VA on August 24, 2010. Where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Therefore, for the non-initial increased rating claims, the Board will only consider evidence submitted one year prior to the filing of the claim for an increased rating, rather than from the initial assignment. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(o)(1); Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is assigned when symptoms such 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 38 C.F.R. § 4.130, DC 9411. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, DC 9411. Under the General Formula for Mental Disorders, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). At the outset, the Board acknowledges an exam scheduling request for PTSD that was recently associated with the claims file pursuant to a "New/Increase" claim dated "10/26/21." However, the evidence submitted on October 26, 2021 was not a new claim for increase, but rather evidence to support his ongoing increased rating claim that is currently on appeal to the Board. Thus, the Board finds that this request was in error and will proceed with adjudication. Reviewing the evidence chronologically, the Veteran filed an increased rating claim that was received by VA on August 24, 2010, stating that his PTSD has worsened, to include his "hands shaking a great deal," and that work had become difficult. In a September 2010 letter in support of the Veteran's claim, his treating VA psychiatrist explained that he has treated the Veteran since 2006 and that his prognosis is guarded. Even with treatment, he continued to experience residual symptoms of PTSD which interfered with his ability to function on an ongoing basis at work, and home stress had contributed as well. In Dr. D.'s opinion, the Veteran's PTSD symptoms caused a reliable decrease in functional productivity on a consistently sustained basis. His symptoms and exacerbations were significant and flare up frequently with or without stress and triggers. Dr. D. observed that the Veteran suffers much more than what appears on the outside, and that his resilience in the areas of coping and stress management was diminishing. In an October 2010 letter in support of the Veteran's claim, the Veteran's counselor explained that there had been an increase in symptoms in the past year and a half. He had become more withdrawn and isolated himself. There was a decrease in pleasure and general loss of interest. There was less intimacy in his marriage, and his short-term memory continued to worsen which negatively impacted his relationship. He had chronic sleep disturbance, which led to heightened anxiety and diminished concentration. He was feeling more depressed and anxious about the future. In October 2010, the Veteran's wife submitted correspondence saying she had personally observed his PTSD symptoms increase in the past year. His hand tremors had become much more prominent, making eating difficult and going out to restaurants very uncomfortable. His depression and anxiety had increased, and he no longer had interest or enthusiasm for anything. He experienced nightmares and trouble sleeping several times a week. He had been having difficulty concentrating at work and became frustrated easily, causing him to come home from work depressed and anxious. According to the Veteran, his constant thoughts of Vietnam impacted his concentration and patience with coworkers. In an October 2010 VA examination, the Veteran was reported to be socially aloof and avoided social contact most of the time. He endorsed cooking and art as hobbies; he had an art studio in his home and was involved in art projects. He had good hygiene but was noted to be very tense with hand tremors throughout the interview. He was difficult to understand due to his low volume of voice. He had a blunted affect and depressed mood, and he was easily distracted with a short attention span. He reported frequent nightmares and panic attacks approximately three times weekly. His short-term memory was mildly impaired. The examiner commented that the Veteran exhibited depressive symptoms including low self-esteem, but no active suicidal intent or plan. His social life was minimal, and the examiner observed that the central issue was self-identity and self-esteem which were disrupted greatly by his participation in the Vietnam war. His sense of well-being was greatly diminished by Vietnam. In terms of the frequency and severity of the symptoms, the examiner observed that the Veteran has had consistent symptoms for many years that tend to wax and wane depending on the stress in his life. The examiner opined that the Veteran experienced occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks, but generally functioned satisfactorily. In an August 2012 letter, Dr. D. explained that the Veteran's prognosis was poor. Even with treatment, he continued to experience residual symptoms which interfered with his ability to function. He opined that due to the Veteran's symptoms, there was a reliable decrease in functional productivity on a sustained basis. His residual symptoms and exacerbations were significant and persisting. Dr. D. expressed concern about the Veteran's diminished resilience in the areas of coping and stress management. In another August 2012 letter from the Veteran's counselor, he explained that the Veteran's PTSD symptoms had worsened from added stress of caring for his wife with muscular dystrophy and bipolar disorder. He felt overwhelmed which resulted in an inability to concentrate and cope with daily stressors. He had heightened anxiety and frequent flashbacks. Due to his health, he retired a year prior but had even more stress due to the demands at home. The stress triggered his PTSD symptoms, particularly an increase in anxiety, which impacted his daily functioning. In a September 2012 VA examination, the examiner opined that the Veteran's symptoms result in occupational and social impairment with reduced reliability and productivity. The Veteran endorsed satisfaction with his marriage, but no contact with his children from a previous marriage. He endorsed poor interactions with other people. His listed symptoms were depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. The Veteran reported thoughts of suicide, though he had no plan or intent. The examiner opined that the symptoms were comparable to those the Veteran was experiencing at the prior October 2010 examination. While his wife believed the symptoms to be worse, the psychological assessments were similar to those measured in 2010. The examiner opined that the symptoms were in the moderate to severe range. The Board acknowledges the Veteran's several statements that he objected to the adequacy of this examination. In his November 2012 Notice of Disagreement, the Veteran stated he retired early to care for his wife who suffers from muscular dystrophy. He stated he had no friends and no one to confide in, which leaves him very lonely, depressed, and anxious. In a March 2014 statement, the Veteran's wife detailed her observations of the Veteran. He wakes up most days depressed before even getting out of bed. He needs to have a routine every day, and if that routine changes, he becomes anxious. He has memory problems and needs reminders for medication and many other daily things. She recalled instances when he forgot to turn the car off in the garage and forgot to turn burners on the stove off. She stated he used to enjoy cooking but can no longer use a knife or open cans or jars due to his tremors. He also becomes irritated and angry with others easily, and as a result has few friends. He becomes very anxious before and during family events, which keep them from going or staying long. He often feels lost and alone. All these symptoms affect their daily lives and marriage. In November 2014, the Veteran's treating psychiatrist and counselor submitted additional letters. Dr. D. reiterated that the Veteran's prognosis remained poor. He observed that the Veteran's condition had declined since retirement. Even with treatment, he continued to experience residual symptoms of PTSD which consistently interfered with his ability to function. Specifically, anxiety and daily intrusive recollections had worsened. Since the Veteran's last rating, his condition required treatment with additional medication. His counselor elaborated that since retirement, the Veteran had more idle time that triggered memories from Vietnam that, until more recently, he had been able to repress. He was now more irritable and angrier, wanting to be alone for longer periods of time. The Veteran's wife accompanied him to appointments and explained that she felt guarded in his presence and concerned of provoking him, which led to tension and isolation between them. From his observation over the past 7 years and professional opinion, the PTSD symptoms were getting more intense. In an April 2015 VA examination, the examiner indicated that the Veteran's symptoms result in occupational and social impairment with reduced reliability and productivity. The Veteran reported days when he wakes up mad and remains so throughout the day. He has been married for 22 years and has been estranged from his daughter throughout his life. He reported few other relationships due to his low patience and being abrupt with others. He stated he stopped driving approximately 4 years ago due to his mind wandering, low concentration, and concerns about judgment. He is still able to complete his regular household chores and complete self-care. In his free time, he enjoyed reading, walking, and in the past has enjoyed art, though his tremors and low patience has stopped these activities. The Veteran's listed symptoms were depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. In his May 2017 hearing, the Veteran endorsed a strictly regimented day that cannot change and likened this routine as almost obsessional or ritualistic. This routine includes self-care and hygiene. He has anxiety attacks almost daily that can last a whole day. He wakes up in the morning angry and often stays angry all day. His life is largely solitary and does not relate to other people well or do well in large groups of people. His mind often wanders, and he is unable to concentrate on tasks. He at times loses his balance and will lose orientation to time and place. He endorsed suicidal thoughts at least once a day. He endorsed nightmares a couple times weekly and flashbacks during the day. His wife testified that he is very short in the mornings and they usually do not communicate for a couple of hours. She must wait until his regimen is completed before they can continue with their day. He has difficulty remaining focused in conversation. In a January 2018 VA examination, the examiner opined that the Veteran's symptoms result in occupational and social impairment with reduced reliability and productivity. The Veteran reported spending much of his time with his wife and having a generally good relationship with her, though he is not an "easy person to live with." He has only a few friends. He does not drive regularly due to a short attention span. He and his wife share household responsibilities. He continues to maintain structure in his days because he does poorly without structure, and it is important for him to take care of himself. He endorsed walking several miles a day and enjoying music. The Veteran's wife discussed his mood swings when he wakes up quiet, angry, and irritable which can last a short time or the whole day. He struggles with eating due to tremors. He does poorly in crowds and small spaces. The Veteran endorsed thoughts of suicide regularly. He reported concerns with thinking and memory. He feels lonely and is often withdrawn and stated that Vietnam seems to impact his daily life. His listed symptoms were depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective relationships, and difficulty in adapting to stressful circumstances. The examiner listed the same functional impairments as in the prior examination. In a February 2018 statement, the Veteran endorsed mood swings and thoughts of Vietnam that influence everything he does. He wakes up depressed and has many dark days where he does not come out of it. He stays away from people and listens to music and reads books. He stays on a schedule and if his schedule is altered, it ruins his whole day. He stated he has no friends and is lonely. In an August 2021 statement regarding how his PTSD affects his employability, the Veteran reiterated his need for a structured routine to reduce anxiety. He is obsessive about personal hygiene. Despite his structured days, he is often depressed and unmotivated. About once weekly he has trouble getting out of bed. He continues to experience nightmares approximately twice weekly, which causes poor sleep and fatigue, and anxiety attacks approximately 3 times weekly. He is hypervigilant when out in public. Driving makes him anxious and his ability to concentrate is poor. His memory is poor, and his wife handles all finances and most household chores. A private medical assessment and opinion was submitted in October 2021. The Veteran continued to endorse his symptoms of hypervigilance, nightmares, physiological reactivity, restricted affect, avoidance and social withdrawal, irritability, low mood, chronic sleep impairment, anhedonia, hopelessness, worthlessness, low self-esteem, decreased appetite, low energy, difficulties with memory, and avoidance and social withdrawal. He explained his need for a regimented daily schedule. The private physician opined that since at least September 2012, the Veteran's PTSD symptoms have resulted in occupational and social impairment with deficiencies in most areas. She specifically cited symptoms of near-continuous panic or depression, suicidal ideation, memory loss and disorientation to time or place, obsessional rituals, and an inability to establish and maintain effective relationships. While it is unnecessary for the Board to reference every relevant treatment record, it is noted that the VA treatment records consistently show individual psychotherapy, group therapy, and marriage counseling throughout the appeal period. While the Veteran has been married for over 20 years, the record clearly shows ongoing marital difficulties and stress that exacerbate his PTSD symptoms. While the Veteran is noted in some records to have many friends and live an active lifestyle, most indicate that the Veteran is isolated and lonely, and has difficulty interacting with others, to include his daughter, other family members, and coworkers prior to retiring. The Veteran's treating physician and counselors' letters in support of the Veteran's claim are highly probative, as they are based on individual treatment and personal observation of the Veteran over several years. The Board affords the private medical opinion significant weight as it thoroughly considers the entire record and provides a detailed and logical rationale for her conclusion. The Board also finds the Veteran and his wife's testimony both credible and probative, as they remain largely consistent throughout the appeal as well as with the treatment records. The Veteran's listed symptoms in the 50 percent criteria are flattened affect, panic attacks more than once a week, impairment of short-term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work relationships. In the 70 percent criteria, the Veteran experiences suicidal ideation, obsessional rituals which interfere with routine activities, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, spatial disorientation, difficulty adapting to stressful circumstances, and inability to establish and maintain effective relationships. The record also reflects chronic sleep impairment due to frequent nightmares, intrusive flashbacks, hypervigilance, anhedonia, and feelings of hopelessness and worthlessness. Not only are the majority of the Veteran's symptoms associated with a 70 percent rating, but the evidence shows that the frequency and severity of the Veteran's symptoms, both listed and unlisted in the criteria, cause occupational and social impairment with deficiencies in most areas of life. Specifically, his obsessional rituals affect his daily life, his marriage, and his ability to function adequately. His near-continuous panic and depression frequently renders him unable to get out of bed. He has shown an inability to establish relationships with others, and in adapting to stressful circumstances such as an unexpected change in his routine. As such, a 70 percent rating is warranted. Entitlement to a 100 percent rating is not shown by the evidence. Not only does the Veteran not experience many, if any, symptoms listed in the rating criteria, but his symptoms are not of such frequency or severity that they cause total occupational and social impairment. He has been able to maintain hobbies and healthy outlets to some degree. He has consistently exhibited clear and logical thought processes, judgment, and orientation with appropriate behavior such that he is able to generally function adequately. The record does not reflect persistent delusions or hallucinations, nor does he present a persistent danger to himself or others that would indicate total impairment. The Veteran's symptoms have stayed largely consistent throughout the appeal period. While some evidence in 2010 reflects an increase in his PTSD symptoms within the year prior, treatment records prior to August 2010 show that the Veteran felt he was appropriately rated. In August 2010, treatment records reflect that the Veteran reported to his treating providers that he felt his symptoms had significantly worsened. Therefore, the Board finds that a 70 percent is warranted as of the date of receipt of claim, August 24, 2010. In sum, the evidence shows that the Veteran is entitled to a 70 percent rating, but no higher, for his PTSD. 2. TDIU The Veteran contends he is unable to work due to his service-connected PTSD. While his claim for a TDIU was not filed until October 2021, evidence of the Veteran's inability to work due to his PTSD has been raised by the record throughout his increased rating appeal. Therefore, a claim for entitlement to a TDIU is part-and-parcel to his increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Harper v. Wilkie, 30 Vet. App. 356 (2018). TDIU may be assigned where the veteran is unable to secure or follow a substantially gainful occupation as a result of their service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a veteran is unemployed or has difficulty obtaining employment is insufficient for TDIU purposes. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The evidence must show the veteran is incapable of performing the physical and/or mental acts required by employment by reason of their service-connected disabilities. In this regard, the United States Court of Appeals for Veterans Claims (Court) has held the phrase "unable to secure and follow a substantially gainful occupation" in 38 C.F.R. § 4.16 has two components: one economic and the other non-economic. Ray v. Wilkie, 31 Vet. App. 58, 73-74 (2019). The economic component contemplates an occupation earning more than marginal income, outside of a protected environment, as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component contemplates the veteran's ability to follow and secure employment. In this respect, due consideration must be given to their history, education, skill, and training; physical ability, both exertional and non-exertional, to perform the types of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue; and mental ability to perform the activities required by the occupation at issue. Given sedentary is defined as "doing or requiring much sitting" the Board finds that sedentary employment is a job where the worker primarily sits down. MERRIAM-WEBSTER'S COLLEGEIATE DICTIONARY 1123 (11th ed.) (2003). In this context, appropriate factors for consideration are the veteran's employment history, educational and vocational attainment and any other factors bearing on the issue. 38 C.F.R. §§ 3.341, 4.16. However, a veteran's age or the impairment caused by nonservice-connected disabilities may not be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19. As a preliminary matter, for TDIU consideration the veteran must meet the disability rating percentage threshold. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. If a veteran is service connected for only one disability, that disability must be rated at 60 percent disabling or more. 38 C.F.R. §§ 4.16 (a), 4.25. If a veteran is service-connected for two or more disabilities, at least one of the disabilities must be rated at 40 percent disabling or more and the additional service-connected disabilities must bring the combined disability rating to 70 percent or more. Id. The Veteran is service connected for PTSD now 70 percent disabling. Therefore, as of this decision, the Veteran has a single disability rating of 60 percent or more effective August 24, 2010 and meets the schedular criteria. The evidence shows that the Veteran retired as a factory assembly line worker in March 2011. In his VA Form 10-8940, he indicated he completed one year of art school and a trade school for an optician for one year in the 1970's. In addition to the evidence already referenced in this decision on how the Veteran's PTSD symptoms affect his ability to work, an August 2010 treatment record reflects that his job had become more difficult due to his increased PTSD symptoms. In October 2010, he relayed that his job was tenuous and due to his health, both physical and mental, he may not be able to stay much longer. In his October 2010 VA examination, his occupational functioning was impaired by decreased concentration and poor social interaction. In the September 2012 VA examination, he reported that he was last employed in May 2011 as a factory line worker, which he relayed he did not enjoy. When asked why he retired, he replied that he simply could not do the job any longer physically or mentally. In his April 2015 VA examination, the Veteran reported that he completed one year of trade school and an apprentice as an optician. He also attended an art school. He last worked in 2011 as a factory worker for 10 years. The job ended due to problems dealing with personnel and a surgery for a heart murmur. He noted negative feedback in terms of efficiency on the job. He noted a few instances of situations where he felt he was close to having physical fights. His longest job was working as an optician for 15 years. He used to volunteer, but because he does not drive, his options are limited. He felt that being abrupt, low patience, and "not playing well with others" would impact his work. The examiner noted functional impairments including resigning from work, conflicts with coworkers, reduced ability to complete tasks efficiently, limited, and strained relationships, and verbal arguments. These same functional impairments were listed in the January 2018 VA examination report. In a statement submitted by the Veteran in August 2021, he explained that he last worked in March 2011 when he resigned from his job as an assembly line worker at a frozen foods manufacturing plant after approximately 15 years. He took time off to recover from heart surgery, though his PTSD impacted his employment as well. When his medical leave expired, he resigned because of the stress brought on by his PTSD. He stated that he had to leave work early approximately once weekly and a few days off a month to mentally refresh due to being overwhelmed at work. The time off caused tension with his manager. He experienced anger and depression while working and would be verbally confrontational with coworkers. He would stay isolated from coworkers during breaks to get through the day. He further stated he had anxiety attacks about 3 times weekly and would have to step away from the production line each time. His work's regimentation and loud factory floor noise often triggered these attacks and brought on flashbacks of Vietnam. He considered suicide many times during his working years. Following retirement, he must keep a structured routine to reduce anxiety. He is often depressed, unmotivated, and has trouble getting out of bed. He continues to suffer from chronic sleep impairment that fatigue him during the day. He has a difficult time being in public and is always hypervigilant. He does not drive. He has a poor memory, and his wife handles the finances and most of the household chores except the cooking, which is a creative outlet for the Veteran. Finally, the Veteran explained that he has a high school education and held many jobs throughout his life, but none involved sitting at a desk. He attended art school for a few years over thirty years ago but did not graduate. His wife handles everything online for them. In the private medical assessment, it was opined that the Veteran's symptoms impair his ability to secure and follow gainful employment and to perform effectively in the workplace. In the private physician's professional opinion, the Veteran would be unable to tolerate average workplace stressors, which could have the potential to decrease the quality of life. In the Residual Functional Capacity Evaluation completed as part of his assessment, it was determined that he would have to miss 3 or more days monthly due to his mental health problems. His attention and concentration would be impaired more than 3 days monthly. Importantly, the Veteran would respond in an angry manner (but not violent) at least once monthly. The private physician cited to medical literature confirming the link between PTSD and unemployment. While the evidence indicates the Veteran left the workforce for multiple reasons, including surgery for his nonservice-connected cardiac condition and to care for his wife, the evidence clearly shows that his increased PTSD symptoms created such significant challenges at work that he could not return. The Veteran's treating psychiatrist, counselor, his wife, and the private physician that assessed him all relayed that his symptoms were increasing. These symptoms rose to such frequency and severity that working became untenable; for example, the Veteran has reiterated his need for an extremely structured daily routine with no flexibility. He has frequent days with such severe depression and anxiety that he is unable to become motivated enough to leave his house, or even his bed. His chronic sleep impairment and memory loss render him fatigued and unable to concentrate. He cannot drive to work due to his short attention span. Even in a position socially isolated from others, the above symptoms are all untenable in both physical or sedentary workplaces. While the Veteran merely lists "March 2011" for his last date of employment, the treatment records indicate he underwent a mitral valve repair on February 25, 2011. As the Veteran has stated he did not return to work following his heart surgery, the Board will assign an effective date of February 25, 2011. An effective date earlier than February 25, 2011 is not warranted. While the record is clear that his PTSD symptoms had increased by August 2010 that made working difficult, the evidence indicates that he engaged in coping mechanisms to function adequately at work until the stressors in other aspects of his life made him unable to do so any longer. In other words, he was able to maintain full-time gainful employment, albeit with difficulty, in a typical workplace with no accommodations, until February 25, 2011. 3. SMC based on housebound status In the October 2021 private assessment, the Veteran relayed that he felt confined to his home as a result of his psychiatric symptoms. As such, the Board finds that the record reasonably raises the issue of whether the Veteran is entitled to SMC. A claim for increased disability compensation may include the "inferred issue" of entitlement to SMC even where the veteran has not expressly placed entitlement to SMC at issue. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). Housebound SMC is available either statutorily or based in fact. Statutory housebound compensation requires the veteran to have a single service-connected disability rated as 100 percent and 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. Housebound-in-fact SMC requires the veteran to have a single service-connected disability rated as 100 percent and be permanently housebound by reason of service-connected disability or disabilities. See 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). A TDIU based on a single service-connected disability can count as a single service-connected disability rating at 100 percent. See Bradley v. Peake, 22 Vet. App. 280 (2008). The Veteran has a single service-connected disability rated at 100 percent based on his TDIU. See Bradley, 22 Vet. App. 280. The Veteran does not meet the requirements for statutory housebound SMC because he does not have a combined 60 percent disability rating independent from a 100 percent rating. However, he may still be eligible for housebound-in-fact. A veteran will be considered housebound where the evidence shows that, as a direct result of his service-connected disability or disabilities, he is substantially confined to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). Substantially confined does not mean that the Veteran is unable to leave his dwelling and the immediate premises at all. Hartness v. Nicholson, 20 Vet. App. 216 (2006); Howell v. Nicholson, 19 Vet. App. 535 (2006). With this legal precedent in mind, the Board finds the Veteran qualifies for house-bound status given the evidence that he is rarely able to leave his home due to his PTSD symptoms of depression and near-continuous panic that causes him to withdraw and isolate. Due to his inability to function in social settings, the Veteran is unable to visit business establishments such as restaurants, and he rarely attends extended family gatherings. Moreover, the Veteran does not drive and often becomes disoriented and forgetful. While the evidence indicates he continues to engage in some level of activity outside the house, including daily bike rides and walks, the Veteran also stated that if it were not for these short daily outings, he would not leave the house at all. As stated above, the meaning of permanently housebound does not require totally and completely housebound. The preponderance of the evidence shows that because of his PTSD, the Veteran is substantially confined to his home. SMC at the housebound rate is granted. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Carroll, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.