Citation Nr: 21073447 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 16-53 775A DATE: December 8, 2021 ORDER Entitlement to a disability rating higher than 60 percent for the service-connected prostate cancer residuals, is denied. Entitlement to a disability rating of 70 percent, but not higher, for the service-connected mental disability is granted. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. Entitlement to special monthly compensation (SMC) on the basis of statutory housebound criteria is granted. FINDINGS OF FACT 1. The service-connected prostate cancer residuals are manifested by continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day, without renal dysfunction. 2. The service-connected mental disability is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but not total occupational and social impairment. 3. The Veteran's service-connected mental disability, now rated at 70 percent, is sufficient on it's own as a single disability to result in the Veteran being unable to secure or follow a substantially gainful occupation. 4. The Veterans has a single disability (mental disability) rated at 70 percent responsible for TDIU; and additional service-connected disabilities rated at 60 percent or more. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 60 percent for the service-connected prostate cancer residuals are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.115a, 4.115b, Diagnostic Code 7528. 2. The criteria for entitlement to a disability rating of 70 percent for the service-connected mental disability are met; the criteria for a 100 percent are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for TDIU are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16. 4. The criteria for SMC based on housebound status are met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from January 1968 to January 1972. He was awarded the Combat Action Ribbon. This appeal comes before the Board of Veterans' Appeals (Board) from a February 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In August 2021, the Veteran and his wife presented testimony at a Board hearing, chaired by the undersigned Veterans Law Judge sitting at the RO. At the Board hearing, the Veteran was informed of the basis for the RO's denial of his claims, and he was informed of the information and evidence necessary to substantiate each claim. 38 C.F.R. § 3.103. The record was held opened for 30 days to submit evidence. A transcript of the hearing is associated with the claims file. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). INCREASED RATINGSLAW AND REGULATIONS Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). The rating must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. 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). Diseases of the genitourinary system generally result in disabilities related to renal or voiding dysfunctions, infections, or a combination of these. The following section provides descriptions of various levels of disability in each of these symptom areas. Where diagnostic codes refer the decision maker to these specific areas of dysfunction, only the predominant area of dysfunction shall be considered for rating purposes. Distinct disabilities may be evaluated separately under this section, pursuant to § 4.14, if the symptoms do not overlap. Since the areas of dysfunction described below do not cover all symptoms resulting from genitourinary diseases, specific diagnoses may include a description of symptoms assigned to that diagnosis. 38 C.F.R. § 4.115a. In the process of evaluating a psychiatric/mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran's psychiatric symptoms and the veteran's capacity for adjustment during periods of remission. After consideration of these factors, and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering rather than based solely on the examiner's assessment of the level of disability at the moment of 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. See 38 C.F.R. § 4.126. The VA Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one General Rating Formula for Mental Disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, the VA Secretary anticipated that any list of symptoms justifying a particular rating would, in many situations, be either under- or over-inclusive. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The schedular criteria incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 38 C.F.R. §§ 4.125, 4.130. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Psychiatric disorders are to be rated on the severity, frequency, and duration their respective signs and symptoms. See Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 ('sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer'); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), Gilbert at 54. Entitlement to a disability rating higher than 60 percent for the service-connected prostate cancer residuals. In an October 2006 rating decision, VA granted service connection for residuals of prostate cancer and assigned an initial disability rating of 100 percent under Diagnostic Code 7528, effective May 3, 2006. In a July 2007 rating decision, the disability rating was decreased to 40 percent, effective October 1, 2007. In a November 2008 rating decision, the disability rating was increased to 60 percent, effective August 5, 2008. The current appeal arises from an increased rating claim received at VA on February 13, 2014. Under Diagnostic Code 7528 malignant neoplasms of the genitourinary system receive a rating of 100 percent. Following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. If there has been no local reoccurrence or metastasis, the residuals are rated as a voiding dysfunction or renal dysfunction, whichever is predominant. Voiding dysfunctions receive a rating of 60 percent with continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day; 40 percent if requiring the wearing of absorbent materials which must be changed 2 to 4 times per day; or 20 percent if requiring the wearing of absorbent materials which must be changed less than 2 times per day. A June 2012 VA heart examination lists cardiac risk factors and, next to "Renal failure" it says "Never." A VA prostate examination in April 2014 reveals the Veteran's complaint of urinary frequency. The examiner reported that the Veteran requires absorbent material that is changed 2 to 4 times per day. He has daytime voiding intervals between 2 and 3 hours, and nighttime awakening to void 2 times. He has hesitancy, slow or weak stream, decreased force of stream, stricture disease requiring dilatation 1 to 2 times per year, and post-void residuals greater than 150 cc. There was no urinary tract or kidney infection indicated. The impact on work consisted of urinary dribbling, and increased intra-abdominal pressure with lifting, or leaning forward. This causes leakage and discomfort with moisture and odor. He will get fatigue and should be able to rest 5 minutes every 60 minutes and change positions and sit if standing every 30 minutes. He cannot do heavy work with forward bending in succession. He could lift 50 pounds 1 to 2 times and 25 pounds frequently. He cannot do running and no climbing. He must avoid heights. He could lose balance because of marked exogenous obesity and physical deconditioning. He could lift 25 to 49 pounds 3 to 4 times in an 8 hour day. He can lift 10 pounds frequently and could carry it upstairs holding on to a bannister. He can do sedentary work with appropriate breaks. The following can be done safely within an 8 hour workday: 1) Lifting/carrying, push/pull, bending/twisting, kneel/squat, stand, sit, climb, drive and/or walk but only stair climbing, not a ladder. 2) grasping/gripping, reaching over head and/or keyboarding. If standing or sitting, he must change positions as needed within reason but sit or stand briefly for 1 to 2 minutes every 30 minutes for up to 5 minutes. He will need frequent bathroom and hygiene breaks. A November 2016 letter from a VA nurse practitioner reports persistent incontinence since his, radical prostatectomy. He continued to have daytime incontinence greater than 12 times per day and his wife reported when they are in the community he has to visit the bathroom immediately at each destination or they have to stop for him to void or to change his incontinent pads. After a review of all of the evidence, the Board finds that the criteria for a disability rating higher than 60 percent are not met. The Veteran is currently receiving the maximum rating for urinary frequency. The only type of genitourinary dysfunction that has a rating higher than 60 percent is renal (kidney) dysfunction. However, renal dysfunction is not shown to exist in this case. The Veteran is separately compensated for erectile dysfunction as a prostate cancer residual, in the form of Special Monthly Compensation (SMC). The Veteran is not receiving compensation for urinary retention, because the rating for urinary frequency is the greater benefit, and as multiple ratings under the schedule for genitourinary system dysfunctions are prohibited. In light of these findings of fact, the Board concludes that a disability rating higher than 60 percent for the service-connected prostate cancer residuals is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Entitlement to a disability rating higher than 50 percent for the service-connected mental disability. In a September 2001 rating decision, VA granted service connection for a mental disability and assigned an initial disability rating of 30 percent under Diagnostic Code 9411, effective March 29, 2001. In a May 2003 rating decision, the disability rating was increased to 50 percent, effective March 29, 2001. The current appeal arises from an increased rating claim received at VA on February 13, 2014. Pertinent to the claim on appeal, the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: A 100 percent rating contemplates 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating, may be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 50 percent rating is warranted if it is productive of 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The Veteran's wife wrote that the Veteran is extremely obsessed with his daily rituals. He gets extremely over excited and agitated in a very negative manner. He has impaired impulse control. He does things for no clear reason and without discussion with her. He is both impulsive and compulsive. When he does have violent outbursts, he is never physical, but very verbally abusive and emotionally abusive. She reported spatial disorientation. He had been tripping and falling and not judging spatial distances accurately. She reported difficulty adapting to stressful circumstances and the inability to establish and maintain effective relationships. He was unhappy, selfish, and depressed. The neighbors were afraid to approach the Veteran because of his demeanor. She described the Veteran as unemployable. A VA mental examination in May 2014 reveals the Veteran's complaint of worrying frequently, stating that "the weight of the world is on me." He occasionally experienced nightmares about comrades that he tried to treat when in Vietnam. He reportedly felt anxiety manifested by picking and scratching at his skin. He denied the experience of panic attacks. He had occasional episodes of shortness of breath and was fidgety. The frequency of nervousness depended on the situation. He reported that the news makes him anxious. He experienced intrusive thoughts of his combat experiences in Vietnam daily in the form of thinking about how he would treat and respond to injuries that he saw on TV. He described his temper as problematic. He denied domestic violence. He denied physical aggression. He denied being verbally abusive. He experienced guilt in the form of second guessing his medical treatment of soldiers. He reported occasional depression that would last for minutes to hours and was also situational. He reported that his startle response to noise had decreased over the years. He avoided thinking and talking about his combat experiences. When asked about feeling emotionally disconnected or numb, he stated, "a little bit." He avoided socializing and stated, "I would rather not deal with people" due to mood swings. He denied depersonalization. He denied derealization. He denied reckless behavior. He reported suicidal ideation and would think about killing himself by driving into a viaduct. He had no intent of acting on these thoughts. He reported that his clinicians knew about his suicidal thoughts. He denied homicidal ideation. His symptoms interfered with his work performance because he withdrew socially and procrastinated at work. He denied missing any days of work and denied being late for work due to symptoms of PTSD. His symptoms interfered with his relationships because he had a low sex drive. He arrived on time for the evaluation, was casually dressed, and in clean clothing. There were no hygiene deficits observed. His attitude toward the evaluation was calm and cooperative, and he appeared to be providing a genuine representation of his symptoms. No unusual movements or psychomotor changes were observed. His speech was normal in rate, tone, and volume, without pressure. His affect was episodically cheerful. His mood was mildly depressed. His thought processes were circumstantial. There was no evidence of hallucinations, delusions, obsessions, compulsions, or phobias observed during the evaluation. Symptoms of PTSD appeared to be moderately interfering with his functioning. The Veteran appeared able to work in a loosely supervised setting. He might become reclusive and irritable due to symptoms of PTSD. The examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity. Symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The examiner diagnosed PTSD. A VA therapist in April 2015 wrote a letter stating that the Veteran's symptoms had been latent and have had their greatest effects later in his life. Symptoms included depressed mood, increased anxiety, chronic anger, and relationship problems. A VA mental examination in January 2016 reveals the Veteran's complaint of nightmares, panic attacks, high anxiety, flashbacks, hypervigilance, angry outbursts, self-blame, emotional detachment, strong negative beliefs about himself and others, avoidance, loss of interest in prior activities, persistent negative emotions, and trouble remembering parts of the trauma. The Veteran feels he is to blame for a lot of things and feels guilty over the way he has treated his wife and children over the years. He is often angry, but puts up a facade and isolates so he doesn't impact others. He does not like to be reminded of his time in Vietnam and becomes emotional in thinking about it. He has constant anxiety regardless of what he is doing. He has nightmares about the jungle and finding body parts. He also experiences feeling emotional, feeling sad, fluctuating appetite, fatigue, and chronic suicidal ideation. He thinks of suicide because he has had enough. He is tired of dealing with all the medical problems that don't seem to end. Once one issue is treated, another one pops up, and it is emotionally draining. There is very little he enjoyshis dogs and his grandchildren. His appetite fluctuates with his mood but no weight loss or gain. He is rarely social, only with his family and the other veterans at the dog park. He denies loss of concentration, poor judgment, poor hygiene, anger resulting in violence or low self-esteem. The Veteran denied current suicidal or homicidal intent, or plan, but had chronic ideation. There was no indication of imminent risk of harm to self or others observed or reported during the examination. There was no evidence of recent inappropriate behavior, agitation or impulsivity, and no indication of preparatory behaviors. Protective factors included family living in the home, ability to identify reasons for living, cultural and religious beliefs that discourage suicide and support living, sense of competency/resilience, family, social support, close relationships, and verbalized ability to implement a safety plan. The Veteran worked at a college as a career services director for 19 years. He said it was a ticking time bomb and he retired rather than having a melt-down at work. The Veteran was casually dressed in jeans and a polo shirt and was adequately groomed. He appeared at ease during the examination; rapport was established. He made good eye contact and his gross psychomotor skills were within normal limits. He was consistently alert and oriented to all spheres and his thought processes were logical and goal directed. He was appropriately interactive and exhibited normal comprehension and expression. He denied perceptual disturbances and no disordered thought processes were observed. He denied homicidal ideation currently but had chronic suicidal ideation. He reported no history of violent behavior. The examiner diagnosed PTSD and depressive disorder. Symptoms included depressed mood, anxiety, panic attacks more than once a week, mild memory loss, such as forgetting names, directions or recent events, and disturbances of motivation and mood. The examiner assessed the severity as occupational and social impairment with reduced reliability and productivity. VA outpatient treatment records can be summarized as showing depressed mood, suicidal ideation, homicidal ideation, irritability and frequent loss of temper, obsessional rituals, but lack of hallucinations or delusions, generally normal orientation, speech, cognition, and thought processes, and good judgment. The Veteran and his wife testified at the Board hearing that he has had flashbacks. The Veteran thought he was in Vietnam when seeing bamboo at an exhibit. He has had episodes of road rage and fighting. He yells at his wife. He is not sociable. His memory is not good. He has suicidal ideation. These symptoms are not suitable to employment. After a review of all of the evidence, the Board finds that the criteria for a disability rating of 70 percent are met; however, the criteria for a total disability rating are not met. The Veteran's symptoms cause deficiencies in family relations and judgment, as demonstrated by his angry outbursts, fighting, and road rage. The Veteran's symptoms cause deficiencies in work and school as demonstrated by his difficulties with interactions with students and employers as described by his former employer. The Veteran's symptoms cause deficiencies in mood, as demonstrated by his diagnosed depression. Thus, there are deficiencies in most areas. These are the criteria for a rating of 70 percent. However, the Veteran retains significant social and occupational function. His impairment is not total. In short, the gross impairment of behavior resulting in severe disorientation of the individual, which is contemplated by the 100 percent rating criteria, is simply not evident in this case at any time. Accordingly, the criteria for a rating of 100 percent are not met. In light of these findings of fact, the Board concludes that a disability rating of 70 percent, but not higher, for the service-connected mental disability is warranted. In denying a total rating, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim to that extent, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. TDIU AND SMCLAW AND REGULATIONS It is the established policy of 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. A finding of total disability is appropriate 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. 38 C.F.R. §§ 3.340(a)(1), 4.15. A claim for a total disability rating based upon individual unemployability presupposes that the rating for the service-connected disability is less than 100 percent, and only asks for TDIU because of subjective factors that the objective rating does not consider. Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran's employability, consideration may be given to his level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The term substantially gainful occupation is not specifically defined for purposes of the regulations governing TDIU. However, marginal employment is not considered substantially gainful employment. Marginal employment includes situations in which an individual's annual income does not exceed the poverty threshold for one person. Employment may be marginal even when the individual's earned income exceeds the poverty threshold if such individual is employed in a protected environment such as a family business or sheltered workshop. 38 C.F.R. § 4.16(a). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: Provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. For the purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). In Hatlestad v. Derwinski, 1 Vet. App. 164 (1991), the United States Court of Appeals for Veterans Claims (Veterans Court) referred to apparent conflicts in the regulations pertaining to individual unemployability benefits. Specifically, the Veterans Court indicated there was a need to discuss whether the standard delineated in the controlling regulations was an "objective" one based on the average industrial impairment or a "subjective" one based upon the veteran's actual industrial impairment. In a pertinent precedent decision, the VA General Counsel opined that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. It was also determined that "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91. Special monthly compensation is payable at a specified rate if a veteran under 38 U.S.C. § 1114(s) when a veteran has a single service-connected disability rated as 100 percent and: (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, separate, and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or, (2) is permanently housebound by reason of service-connected disability or disabilities. 38 C.F.R. § 3.350(i). For the purpose of meeting the first criterion, a rating of 100 percent may be based on any of the following grants of total disability: on a schedular basis, on an extraschedular basis, or on the basis of a temporary total rating pursuant to 38 C.F.R. §§ 4.28 (pre-stabilization rating), 4.29 (temporary total hospital rating) or, 4.30 (temporary total convalescence rating). Additionally, a total disability rating based on individual unemployability (TDIU) may meet the criterion, but only if assigned for a single disability. See Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242 (2011). While the separate disabilities rated as 60 percent disabling must involve separate and distinct anatomical segments or body systems, the fact that the total disability and the independent 60 percent disabilities result from a common etiological agent will not preclude entitlement. With regard to the permanently housebound requirement, this is met where a veteran is substantially confined as a direct result of a service-connected disability to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinic areas, and it is reasonably certain that the disability or disabilities and resulting confinement will continue throughout his or her lifetime. Id Entitlement to TDIU. Entitlement to SMC. The Veteran maintains that coronary artery disease, PTSD, and prostate cancer prevent employment. The date of claim is February 13, 2014. In view of the higher ratings assigned herein, for the entire period on appeal and in accordance with the Combined Ratings Table under 38 C.F.R. § 4.25, the Veteran is in receipt of a combined disability rating of 100 percent. However, a total disability rating does not moot the issue of TDIU entitlement, as TDIU can be used to satisfy the criteria for SMC if it can be supported by a single disability. See Bradley v. Peake, 22 Vet. App. 280 (2008) On the VA Form 21-8940 (Veterans Application for Increased Compensation Based on Unemployability) the Veteran reported that he last worked full time in April 2015 in career services. The Veteran's former employer wrote in April 2015 that the Veteran's job required adhering to a strict appointment schedule, extensive travel, and interacting with students, employers, and employees. He struggled to meet these requirements. It was noted that the company would not be able to accommodate his medical needs and had no positions he would be eligible for. Based on the evidence provided by the Veteran's former employer, and by the Veteran, the Board finds that the Veteran's service connected mental disability, rated as 70 percent disabling, is sufficiently impairing to support a TDIU rating without consideration of additional disabilities. The type of employment for which the Veteran has training, and job experience requires personal interaction and engagement. These qualities are highly affected by his service-connected mental disability, which includes symptomatology of social withdrawal and irritability. The Veteran has such occupational impairment as would reasonably render him unable to find employment in the type of activities which his education and job experience would support. To the extent of any reasonable doubt on this issue, the Board resolves such doubt in favor of the claim. The Board finds that the service-connected disabilities render the Veteran unable to secure or follow a substantially gainful occupation. Accordingly, the Board concludes that TDIU is warranted for the entire period. The Board also finds that as the Veteran has a single disability (mental disability) rated at 70 percent but solely responsible for TDIU and additional disabilities rated at 60 percent or more, SMC on statutory housebound criteria is warranted. As this represents the full benefit sought on appeal, there is no prejudice resulting from any deficiency in the duties to notify or assist. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Cramp 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.