Citation Nr: 21072363 Decision Date: 12/03/21 Archive Date: 12/02/21 DOCKET NO. 95-15 875 DATE: December 3, 2021 ORDER Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with insomnia disorder for the period from January 31, 2007 to December 5, 2019, is denied. Entitlement to special monthly compensation (SMC) pursuant to 38U.S.C. §1114 (s) prior to December 5, 2019 is denied. FINDINGS OF FACT 1. For the period from January 31, 2007 to December 5, 2019, posttraumatic stress disorder (PTSD) with insomnia disorder more nearly approximated occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood, as contemplated by a 70 percent rating. 2. Prior to December 5, 2019, the Veteran did not have a single disability rated as total, to include consideration of a TDIU based solely on a single service-connected disorder. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with insomnia disorder for the period from January 31, 2007 to December 5, 2019 have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. Prior to December 5, 2019, entitlement to SMC pursuant to 38 U.S.C. § 1114 (s) is not warranted. 38 U.S.C. § 1114 (s); 3 8C.F.R. § 3.350 (i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1991 to June 1994. These issues came to the Board of Veterans' Appeals (Board) in August 2017. The Board remanded both claims, among several others, so that the Agency of Original Jurisdiction (AOJ) could issue a Statement of the Case (SOC) pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). The issues returned to the Board after the SOC was issued. In a February 2018 decision, the Board denied, among other issues, entitlement to a rating in excess of 50 percent PTSD and entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (s). The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In February 2019 the Court, pursuant to a Joint Motion for Partial Remand (JMPR) filed on behalf of the parties, partially vacated the Board's February 2018 decision denying entitlement to an increased rating for PTSD and entitlement to SMC. Specifically, the Court directed the Board to consider a February 2016 VA mental health record showing the Veteran reported thoughts about taking his life "years ago." See October 2018 JMPR, pages 3-4. The Veteran's claim for SMC was vacated as inextricably intertwined with his increased rating claim for PTSD. The Board remanded the Veteran's claims in an October 2019 decision to provide a new examination for PTSD, which he was provided on December 5, 2019. The Board's prior remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In an August 2020 rating decision, the Agency of Original Jurisdiction granted a 100 percent rating for PTSD and entitlement to SMC under 38 U.S.C. § 1114 (s) at the housebound rate, effective December 5, 2019. The increased rating and award of SMC constituted a partial grant of the benefits sought on appeal. The Veteran continues to seek a 100 percent rating for PTSD and SMC prior to December 5, 2019. In an October 2020 decision, the Board granted entitlement to a 70 percent rating for PTSD for the period from January 31, 2007 to December 5, 2019, denied entitlement to a 100 percent rating for PTSD for the same period, and denied entitlement to SMC under 38 U.S.C. § 1114 (s). The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In June 2021 the Court, pursuant to a second Joint Motion for Partial Remand (JMPR) filed on behalf of the parties, partially vacated the portions of Board's October 2020 decision that had denied entitlement to a 100 percent evaluation to PTSD and entitlement to SMC. The parties agreed the Board had failed to provide an adequate statement of reasons and bases by failing to adequately apply 38 U.S.C. § 5110 (a) when it determined the Veteran's PTSD did not meet the criteria for a 100 percent rating and by failing to adequately address a May 2019 lay statement where the Veteran contended the severity of his PTSD and suicidal thoughts remained constant, that he was confined to his home, and was "completely unable to adjust with social, family, and ongoing life due to severe depression, anxiety, and sleep disorder." See June 2021 JMPR, pages 2-4. SMC was vacated as inextricably intertwined with the increased rating claim for PTSD. These matters return to the Board for further consideration consistent with the terms of the June 2021 JMPR. INCREASED RATING 1. Increased rating for posttraumatic stress disorder (PTSD) with insomnia disorder from January 31, 2007 to December 5, 2019. As noted above, the AOJ granted a 100 percent rating effective December 5, 2019, and the Board granted a 70 percent evaluation for the period from January 31, 2007 to December 5, 2019. The Veteran currently seeks a 100 percent evaluation for that period. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R., Part 4. The ratings are intended to compensate impairment in earning capacity due to a service-connected disease or injury. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Diagnostic Code 9411 pertains specifically to PTSD. Except for eating disorders, all mental disorders including PTSD are rated under the General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, a 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating requires 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. 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. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. 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 solely on the basis of social impairment. 38 C.F.R. § 4.126. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 U.S.C. § 1155; 3 8C.F.R. §§ 4.1, 4.2, 4.7. The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, as the Court pointed out, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Additionally, "[a] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. After reviewing the evidence, the Board concludes that a 100 percent evaluation for PTSD and insomnia is not warranted before December 5, 2019. The Veteran had multiple VA mental health examinations during the relevant period on appeal. He was also provided an examination on December 5, 2019, which the AOJ used as the basis to grant a 100 percent rating. He was afforded a VA examination in April 2012. The examiner noted diagnoses of anxiety disorder and depressive disorder. The examiner listed symptoms attributable to anxiety disorder of chronic worrying, anxiety, mistrust of others and difficulty falling asleep. Symptoms attributable to depressive disorder were irritability, periods of hopelessness, poor appetite, lack of interest, diminished affect, isolation, unmotivated and "just passing through life. "The examiner indicated that the Veteran's level of occupational and social impairment in regards to his mental diagnoses was best summarized as "[o]ccupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." The Veteran reported he was married and had two children and a stepchild living with him and his wife. He denied having a social life and stated that he mistrusts others and does not believe in friendships. Arguments with his wife were referenced. The Veteran had not worked since 2006 and stopped working due to stress. He also reported that he had recently looked for work and was offered a job that was declined when they learned he had poor credit. He had interviewed in December 2011 but got discouraged and had not interviewed since. On mental status examination, the examiner noted that speech was of normal rate and volume with a deflated, flattened tone, that affect was restricted and tense, and that mood was dysthymic. Thought process was linear with normal content, memory and concentration were good, insight was fair, and judgement was good. The Veteran denied suicidal and homicidal ideation. Depressed mood, anxiety, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships were attributed to his diagnoses. The examiner determined that the psychiatric diagnoses do not appear to render the Veteran unable to sustain employment, noting that the Veteran "is able to participate in interviews, care for his children, and travel/move his family overseas. He expressed interest in finding work though stated the job market is changed and the economy is poor, causing him difficulty in finding work." See April 2012 VA Examination Report. He was afforded another VA examination in March 2014. The examiner noted a diagnosis of insomnia disorder. The Veteran reported difficulty falling and staying asleep, that he feels fatigued upon waking, and that he sleeps 4 to 5 hours per night. He had been married to his second wife for seven years and had four children, and reported he was unemployed due to physical and emotional problems. He had problems with depression, anxiety, and chronic sleep impairment. Regarding symptoms, the examiner noted depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner noted that the Veteran was appropriately dressed and well-spoken and that he was annoyed and frustrated at being at the examination. The Veteran also reported that sleep impairment has a clinically significant effect on his occupational functioning, and that he had to quit his last job due to sleep difficulties and stress associated with the commute. The examiner indicated that the Veteran's level of occupational and social impairment in regard to his mental diagnosis was best summarized as "[o]ccupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." The Veteran was afforded another VA examination in January 2016. PTSD was diagnosed. The Veteran was married and had five children and was still unemployed. The examiner noted that the Veteran was pleasant but tends to be withdrawn. He could manage his financial affairs. Regarding symptoms, the examiner recorded depressed mood, anxiety, chronic sleep impairment, flattened effect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and inability to establish and maintain effective relationships. The examiner determined the Veteran had "[o]ccupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." The Veteran was afforded a VA examination in December 2019. The Veteran reported that he had separated from his wife of 15 years in September 2019 and had been unemployed since 2006. He described his current emotional health as depressed and anxious, that past things bothered him too much, and that he was too tired and depressed. He endorsed frequent moods including depression, anxiety, stress, and excessive anger. Current symptomatology included sad feelings, problems with sleep, loss of motivation, loss of interest in previously enjoyable activities, loss of appetite, weight loss, feelings that no one cares, feeling hopeless, negative thoughts, frequent sense of discouragement, feeling restless, irritability, increased muscle tension, concentration problems, being easily distracted, nightmares, traumatic memories, avoiding these memories, hypervigilance, decreased sexual interest, and low self-esteem. He also reported that the depression and anxiety had worsened with a loss of functioning, no work, and a loss of productivity. He denied panic attacks. He reported he has had thoughts of suicide and denied any serious consideration of suicide at the time of this examination. He also denied experiencing any hallucinations or delusions. Regarding symptoms, the examiner noted depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, flattened effect, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, inability to establish and maintain effective relationships, suicidal ideation, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Under behavioral observations, the examiner noted the Veteran was a reliable historian and orientation was within normal limits. His appearance was somewhat disheveled, and hygiene was poor. Behavior was appropriate and he maintained good eye contact during the exam. His energy level was low, and his mood was severely depressed. His affect was flat and there were no signs of distress. Communication was within normal limits, speech was within normal limits, and concentration was within normal limits. Judgment was not impaired, abstract thinking was normal, and memory was within normal limits. Suicidal ideation was present with passive thoughts but there were no active plans of suicide. The examiner determined the Veteran's mental diagnoses caused total occupational and social impairment. As noted above, the AOJ increased the rating of the Veteran's PTSD to 100 percent effective December 5, 2019, the date of the examination. VA mental health treatment records during the period on appeal show the Veteran received individual mental health treatments, medication management, and attended group therapy. VA treatment notes dated March 2012, May 2012, August 2012, September 2012, December 2012, March 2013, August 2016, September 2016, and October 2016 noted the Veteran to be groomed, to have appropriate or euthymic mood, to have regular and fluent speech, to have linear thought process, to be alert and oriented, to have grossly intact memory, and to have good or adequate insight and judgment. Pertinently, he also denied suicidal and homicidal ideation. His affect was variously noted as "constricted yet responsive," "normal range, appropriate to thought content" and "euthymic and responsive." In March 2012 the Veteran reported that "past divorce and work stress lead to leaving his job" and that "doing computer work and he will not do it again because it was so stressful." He also reported that he did not like being around too many people outside of his immediate family and siblings. He denied suicidal and homicidal thoughts and there was no evidence of psychosis. Thought process was noted as linear and goal oriented, the Veteran was cognitively stable and alert, and was oriented with good insight and judgment. A self-assessment indicated severe depression. In May 2012 he reported that his main job was taking his kids to and from school and that he falls into depression when he is not engaged in activity. He stated that no one is close to him but that he is not close to anyone either and does not want to be. In October 2012 he reported that his depression is never good and that he never feels good, that his family is always an issue, and that he argus with his wife. Another October 2012 record shows the Veteran reported that he was "doing well psychiatrically" and denied homicidal and suicidal thoughts. Although his affect was constricted, he was responsive, mood was appropriate, and there was no evidence of psychosis. He was cognitively stable, alert, oriented, with good insight and judgment. Very similar notes were made during mental health sessions in March 2013. During a May 2016 appointment the Veteran reported depressed mood, low energy, low motivation, irritability, decreased focus and concentration, memory issues, anxiety, restlessness, hypervigilance, and intrusive thoughts. She denied suicidal or homicidal ideation. He reported sleeping fair but had infrequent nightmares. Behavior was noted as good with no safety issues, and there were no manic or psychotic symptoms. The examiner noted the Veteran was groomed and cooperative, mood was depressed and affect constricted, thought processes were linear and goal directed, judgment and insight were adequate, the Veteran was oriented and alert, and attention and memory were sustained and intact. An August 2016 note shows that the Veteran reported he was doing much better, that he was less depressed and less irritable, had no nightmares, was sleeping fair, and had no suicidal thoughts. An October 24, 2016 note shows the Veteran reported he continues to do well on medication, that his mood was stable, he was less irritable and anxious, and was sleeping well with infrequent nightmares. He continued to struggle with his wife and their communication problems were getting worse. The Veteran attended individual and group therapy sessions throughout 2016 and 2017 and reported severe symptoms in PCL-5 PTSD checklists. April 2019 psychology notes show the Veteran reported sleep troubles and waking up in the middle of the night. However, the treating psychologist noted the Veteran was cooperative, alert and oriented, that his speech and psychomotor habits were within normal limits, that he denied suicidal and homicidal ideation, there were no symptoms of psychosis or mania, that his thought process was organized, and his insight and judgment were good. Similar notes were taken at a May 2019 followup. After reviewing the evidence, the Board concludes that a 100 percent rating is not warranted for the Veteran's PTSD before December 5, 2019. The level of impairment more closely approximated the criteria for the assigned 70 percent evaluation. The Board acknowledges that the Veteran's symptoms have fluctuated in severity throughout the period on appeal. Overall, the Board finds that the Veteran's symptomatology did more nearly approximate the frequency, severity, and duration of symptoms contemplated by the criteria for a rating of 70 percent. See 38 C.F.R. § 4.7. The Board finds it highly probative that VA examiners in April 2012, March 2014, and January 2016 estimated the Veteran's overall level of impairment was below the total occupational and social impairment required for a 100 percent evaluation. The January 2016 examiner determined the Veteran's symptoms caused him occupational and social impairment, with deficiencies in most areas, corresponding with a 70 percent rating. In October 2020 the Board granted a uniform 70 percent evaluation after accepting the Veteran had a consistent level of impairment throughout the period on appeal, albeit with fluctuating symptoms. However, a rating in excess of 70 percent is not warranted. Before December 5, 2019, he denied suicidal ideation, there was no indication of any obsessional rituals interfering with routine activities, there is no indication his speech was ever illogical, obscure, or irrelevant, his depression and panic did not affect his ability to function independently, appropriately, or effectively, his impulse control was not impaired, there was no spatial disorientation, and he did not neglect his personal appearance or hygiene. The more severe symptoms outlined specifically in the diagnostic criteria for a 100 percent evaluation were not shown in the 2012, 2014, or 2016 VA examinations, or in the VA mental health treatment records. The Board notes that the Veteran has been depressed and had anxiety. Near-continuous depression is a factor in a 70 percent rating, but the VA examinations and mental health treatment records do not suggest the Veteran's depression affected his ability to function independently, appropriately, or effectively. Rather, the examiners and treating mental health professionals indicated his behavior and functioning was essentially normal during treatment, although his mood and effect were often depressed. The Board finds that the severity of the Veteran's symptomatology was more consistent with the level of occupational and social impairment contemplated by a 70 percent disability rating. A 100 percent rating requires a level of total occupational and social impairment due to symptoms such as, or of a similar severity 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, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411. None of these specific symptoms have been shown during VA treatment sessions or VA examinations during the period on appeal. The VA psychiatric records highly probative in this regard, which suggest a level of symptoms and impairment below total occupational or social impairment. The "such symptoms as" language used to rate mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan, 16 Vet. App. at 422. However, without those examples in the 100 percent criteria, differentiating a 70 percent rating from a 100 percent rating would be ambiguous, and the list of examples in the 100 percent criteria "provides guidance as to the severity of symptoms contemplated for each rating." Id. Furthermore, "[a] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio, 713 F.3d at 117. Here, the lack of any symptoms approximating the listed criteria for a 100 percent evaluation, combined with the VA treatment records and three relevant VA examination reports, is convincing evidence that the Veteran's symptoms did not more closely approximate the criteria for a 100 percent evaluation. While severe social impairment has been demonstrated, a 100 percent evaluation cannot be assigned solely based on social impairment. See 38 C.F.R. § 4.126. In addition, the Veteran's inability to establish or maintain effective relationships is a factor explicitly contemplated by the assigned 70 percent evaluation. Furthermore, the Board finds it highly probative that multiple VA examiners determined the Veteran's psychiatric symptoms did not cause total occupational impairment during the appeals period. The Veteran has difficulty in work and worklike settings and an inability to establish and maintain effective relationships both in work and socially. Although significant occupational impairment is demonstrated, the Veteran's level of impairment is contemplated by the assigned 70 percent evaluation. The Veteran has overall been found to have appropriate thought process and communication and has been oriented to time and place. He has also denied being a danger to himself and others, although he has described inadvertently harming others while sleeping during nightmares. He does not have symptoms such as delusions, hallucinations, or paranoia. The record as a whole does not support the existence of symptoms such that there is total occupational and social impairment. VA examinations reflect that, during the period on appeal, the Veteran's PTSD and insomnia result in depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, flattened affect, disturbances of mood and motivation, and difficulty or inability to establish and maintain effective work and social relationships. All these symptoms are contemplated by the 70 percent evaluation. While the Veteran did occasionally report memory problems, the criteria for a 70 percent evaluation do consider impairment of short- or long-term memory, which is listed in the criteria for a 50 percent evaluation. The level of memory impairment required for a 100 percent evaluation is not shown. The above-listed medical records show the Veteran has overall been found to have appropriate thought process and communication, has been oriented to time and place, and has routinely denied suicidal or homicidal thoughts. He does not have delusions, hallucinations, or psychotic manifestations. The Board has considered the Veteran's lay statements of record. VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability or death benefits. 38 U.S.C. § 1154 (a); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence, the lack of contemporaneous medical evidence can be considered and weighed against an appellant's lay statements. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Here, the Veteran generally asserts that his PTSD symptoms have remained consistent throughout the period on appeal and warrant a 100 percent evaluation. The Board also acknowledges that the Veteran submitted a statement dated May 11, 2019 indicating that the severity of his PTSD with suicidal thoughts remains consistent, that he was confined to his house, and that he was "completely unable to adjust with social, family, and ongoing life due to severe depression, anxiety, and sleep disorder". The Veteran is competent to provide evidence of which he experiences, including his symptoms and their severity. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran's lay statements, including the May 11, 2019 statement, are remarkably inconsistent with his contemporaneous presentation and complaints during VA psychiatric treatments. The Veteran routinely denied experiencing such symptoms Additionally, he regularly reported doing well during VA psychiatric appointments. Multiple VA health professionals throughout the appeals period noted depressive and anxiety symptoms, but also noted that the Veteran was cooperative, alert and oriented, that his speech and psychomotor habits were within normal limits, that he denied suicidal and homicidal ideation, there were no symptoms of psychosis or mania, that his thought process was organized, and his insight and judgment were good. When weighing evidence, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). The Board ultimately finds the Veteran's lay assertions submitted in support of his claim are far less credible than his contemporaneous statements made during VA psychiatric treatments and the observations of skilled professionals. In a May 2019 lay statement the Veteran stated that the severity of his PTSD with suicidal thoughts remained consistent, that he was confined to his home, and completely unable to adjust with social, family, and ongoing life. However, four days prior on May 7, 2019 the Veteran denied any suicidal ideation during a VA psychiatric appointment. The Board also notes that the Veteran is not confined to his home, as indicated by VA treatment records. The Veterans assertions of suicidal ideations before December 5, 2019 are remarkably inconsistent with the medical evidence and his own reporting at VA mental health treatment sessions. See Rucker v. Brown, 10 Vet. App. 67 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care); Struck v. Brown, 9 Vet. App. 145 (1996) (statements made while seeking medical treatment are significant and given significant weight and credibility because they were made at a time when there is no incentive, financial or otherwise, to fabricate information for personal gain.). The Board assigns great probative value to the Veteran's regular denials of suicidal or homicidal ideation before December 5, 2019. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). Additionally, even if the Veteran has had suicidal ideation during the period on appeal, suicidal ideation is explicitly contemplated by the assigned 70 percent evaluation. See 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent evaluation would require total occupational or social impairment, which was not shown before the December 5, 2019 VA examination, or that the Veteran represented a persistent harm to himself or others, which the more probative evidence does not show. Finally, the June 2021 Joint Motion for Partial Remand states the Board had erred in the October 2020 decision by failing to adequately apply 38 U.S.C. § 5110 (a) when it determined the Veteran's PTSD did not meet the criteria for a 100 percent rating for the period of January 31, 2007 to December 5, 2019. Specifically, the Joint Motion states the Board had erred by failing to discuss the Veteran's May 2019 lay statement, where he reported that "my severity of PTSD with suicidal thoughts remain constant", he was "confined to the home", and "completely unable to adjust with social, family, and ongoing life due to severe depression, anxiety, and sleep disorder" when it accepted December 5, 2019, the date of a VA examination, as the effective date of the Veteran's 100 percent evaluation for PTSD. See June 2021 Joint Motion for Partial Remand, pages 3-4. As explained above, the Board has found the Veteran's May 2019 lay statement far less credible than the contemporaneous medical records, suggesting a much lower level of impairment than what the Veteran described. The date of entitlement is not the date that VA receives evidence or necessarily the date of that evidence; rather, it is the date that the evidence establishes entitlement began, subject to the limitation of 38 U.S.C. § 5110. See June 2021 Joint Motion for Partial Remand, page 3 (citing DeLisio v. Shinseki, 25 Vet. App. 45, 5859 (2011)). The evidence before December 5, 2019 does not show that the Veteran's psychiatric symptoms more closely approximated the level of impairment contemplated by a 100 percent evaluation. Rather, the credible and probative evidence establishes the Veteran's psychiatric symptoms more nearly approximated the criteria of the currently assigned 70 percent evaluation. U.S.C. § 5110 provides that the effective date of an award based on an initial claim shall be fixed in accordance with the facts found. The Board finds that, given the Veteran's less credible lay statements, an increase in the Veteran's PTSD was not discernable until the December 2019 VA examination report finding total occupational and social impairment. In sum, the severity of the Veteran's symptoms has fluctuated over time. Different VA examiners and mental health providers have described his manifestations differently. The Veteran's lay statements regarding the severity and frequency of his symptoms is vastly different than what he reported during VA mental health appointments and psychiatric examinations. Overall, the Board finds that the Veteran's symptomatology more nearly approximated the frequency, severity, and duration of symptoms contemplated by the criteria for a rating of 70 percent. See 38 C.F.R. § 4.7. Throughout the appeal period, the Veteran's service-connected posttraumatic stress disorder with insomnia disorder more nearly approximated the frequency, severity, and duration of symptoms contemplated by a 70 percent rating. The criteria for a 100 percent evaluation were not more nearly approximated. 2. Entitlement to SMC pursuant to 38 U.S.C. § 1114 (s) prior to December 5, 2019. The Veteran seeks entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114 (s). In the May 2014 Notice of Disagreement and an accompanying written statement, he referenced homebound and housebound with respect to SMC and referenced that he was not applying for aid and attendance. SMC by reason of being housebound is payable if a Veteran has a service-connected disability rated as total and either: (1) has an additional service-connected disability or disabilities independently ratable at 60 percent or more; or (2) is permanently housebound by reason of his service-connected disability or disabilities. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). Here, the Veteran did not have a single disability rated as total based on the schedular criteria before December 5, 2019, when the AOJ increased the rating for PTSD to 100 percent and awarded SMC at the housebound rate effective the same date. In a December 2017 brief, the Veteran's representative stated that: The TDIU also plays a significant role in the veteran's pursuit of SMC at the housebound rate where the veteran notes that while his TDIU may be warranted for multiple conditions, it can also now be ascribed singly to the service-connected PTSD. When TDIU is warranted for a single service-connected disability, then the remaining service-connected conditions are for consideration in determining whether the veteran meets the criteria for the schedular assignment of a statutory housebound rating. Bradley v. Peake, 22 Vet. App. 280 (2008). A similar argument was advanced by a different representative in an August 2019 Appellant's Brief The Veteran has been in receipt of a TDIU since February 25, 2006. The TDIU was granted in a March 2016 rating decision on the basis that recent VA examinations had shown the Veteran's service-connected disabilities, including his PTSD, rendered him unable to obtain or sustain substantially gainful employment. The TDIU was not initially granted based on PTSD only. A preliminary of the issues before the Board is whether the Veteran's service-connected PTSD, by itself, resulted in the Veteran being unable to secure or follow a substantially gainful occupation prior to December 5, 2019. If PTSD alone rendered the Veteran unemployable, then the Veteran would have a single disability rated as total for SMC purposes pursuant to 38 U.S.C. § 1114 (s). See Bradley v. Peake, 22 Vet. App. 280, 293 (2008) (Holding that the current regulation permits a TDIU rating based on a single disability to satisfy the statutory requirement of a total rating). The Veteran has other service-connected disabilities independently rated at 60 percent or more since June 25, 1994. After reviewing the evidence, the Board finds that the Veteran's PTSD alone did not render him unable to secure or follow a substantially gainful occupation prior to December 5, 2019. As addressed in detail above, a 70 percent disability is warranted for the Veteran's PTSD with insomnia prior to December 5, 2019. Overall, the Board finds the Veteran's psychiatric symptomatology was not alone of the severity that would result in him being unable to secure or follow a substantially gainful occupation. In this regard, the Board finds probative the VA treatment notes dated over a multi-year period. In October 2012 the Veteran reported that he was "doing well psychiatrically" and denied homicidal and suicidal thoughts. Although his affect was constricted, he was responsive, mood was appropriate, and there was no evidence of psychosis. He was cognitively stable, alert, oriented, with good insight and judgment. Very similar notes were made during mental health sessions in March 2013, September 2016, and October 2016. April 2019 psychology notes show the Veteran reported sleep troubles and waking up in the middle of the night. However, the treating psychologist noted the Veteran was cooperative, alert and oriented, that his speech and psychomotor habits were within normal limits, that he denied suicidal and homicidal ideation, there were no symptoms of psychosis or mania, that his thought process was organized, and his insight and judgment were good. Similar notes were taken at a May 2019 followup. Such statements over a prolonged period, including as late as May 2019, indicate that the severity of the Veteran's was not of the level that would result in him being unable to secure or follow a substantially gainful occupation. The Board acknowledges that the Veteran submitted a statement in May 2019 indicated that his PTSD caused him to be confined to his home and completely unable to adjust with social and family life due to his symptoms. However, this statement is inconsistent with his contemporaneous presentation and complaints during VA psychiatric treatments. As explained in greater detail above, the Board ultimately finds the Veteran's lay assertions that his PTSD is severe enough to confine him to his home far less credible than his contemporaneous statements made during VA psychiatric treatments and the observations of skilled professionals. Also probative are the findings of VA examiners in April 2012, March 2014, and January 2016, who all determined the Veteran's psychiatric symptoms caused less-than total occupational impairment. Furthermore, a review of the relevant evidence throughout the period on appeal suggests multiple reasons why the Veteran was unable obtain employment. A March 2013 VA mental health note shows the Veteran was frustrated in finding a job and that he was unable to get a security clearance for jobs he was qualified for. At the April 2012 VA examination, the Veteran reported that he was unable to get hired for a job due to bad credit, and the examiner determined the Veteran's psychiatric symptoms did not at that time appear to render him unable to sustain employment, that he was able to participate in interviews, that he had expressed interest in finding work, and had stated the job market is changed and the economy is poor, causing him difficulty in finding work. See April 2012 VA Examination Report. The Veteran had also reported that it was financially more beneficial for him to remain unemployed rather than work. See, e.g., March 18, 2016 Mental Health Note. These statements tend to suggest that the Veteran's service-connected psychiatric disorder alone did not render him unable to secure or follow a substantially gainful occupation before December 9, 2019. The Board does not question that the Veteran's psychiatric symptoms now cause total occupational impairment. See December 5, 2019 VA Examination Report. The Board also accepts that the Veteran's psychiatric symptoms impacted his ability to work before December 5, 2019. Such impairment is reflected by the 70 percent evaluation for PTSD in effect before such date. However, the preponderance of the evidence is against finding the Veteran's service-connected PTSD alone resulted in the Veteran being unable to secure or follow a substantially gainful occupation during the period on appeal. As such, the TDIU is not in effect for the Veteran's PTSD alone, and prior to December 5, 2019, the Veteran did not have a single service-connected disability rated as total along with additional service-connected disability or disabilities independently ratable at 60 percent or more. The Board also notes that, although the Veteran has reported being housebound for much of the period on appeal, VA treatment records indicate he has been independent in almost all activities of living, has traveled with his family, and has attended various appointments throughout the period relevant to the appeal. He is not actually substantially confined to his home or the immediate premises due to service-connected disability. See 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). In sum, the Board finds that the Veteran was not unable to secure or follow a substantially gainful occupation as a result solely of his service-connected psychiatric disorder prior to December 5, 2019. Accordingly, the Board finds that the Veteran did not have a single disability rated as total, to include consideration of a TDIU based solely on an acquired psychiatric disorder. As such, the Board concludes that entitlement to SMC pursuant to 38 U.S.C. § 1114 (s) is not warranted. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morse 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.