Citation Nr: 21005591 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 20-11 006 DATE: February 2, 2021 ORDER Entitlement to a compensable rating for bilateral hearing loss is denied. Entitlement to a rating in excess of 70 percent prior to August 1, 2020 for other specified trauma- and stressor-related disorder is denied. Entitlement to a 70 percent rating for trauma-related disorder from August 1, 2020 is granted, submitted to the laws and regulations governing the payment of monetary benefits. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to special monthly compensation based on aid and attendance allowance for a dependent spouse is denied. FINDINGS OF FACT 1. The Veteran demonstrated Level I acuity in the right ear and Level VIII acuity in the left ear. 2. During the appeal period, the Veteran’s service-connected other specified trauma- and stressor-related disorder is not manifested by total occupational and social impairment. 3. From August 1, 2020, the Veteran’s trauma-related disorder is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 4. The Veteran’s service-connected other specified trauma- and stressor-related disorder prevents him from obtaining and maintaining substantially gainful employment. 5. The competent evidence does not establish that the Veteran’s spouse is bedridden, unable keep herself clean and presentable, unable to feed herself because of the loss of coordination of upper extremities or because of extreme weakness, unable to attend to the wants of nature, or has physical or mental incapacity requiring care or assistance on a regular basis to protect her from the hazards or dangers of her environment. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.85, Diagnostic Code (DC) 6100. 2. For the entire appeal period, the criteria for a rating in excess of 70 percent for other specified trauma- and stressor-related disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.126, 4.130, DC 9411. 3. From August 1, 2020, the criteria for a 70 percent rating, but no higher, for other specified trauma- and stressor-related disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.126, 4.130, DC 9411. 4. The criteria for a TDIU have been met. 38 U.S.C. § 1155; 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(b). 5. The criteria for special monthly compensation based on aid and attendance allowance for a dependent spouse have not been met. 38 U.S.C. §§ 1114, 1521, 5107; 38 C.F.R. §§ 3.102, 3.351, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from February 1966 to December 1968. This matter is on appeal before the Board of Veterans’ Appeals (Board) from a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) rating decision dated in September 2017. The Board acknowledges that the AOJ notified the Veteran of a reduction in the rating assigned his service-connected trauma-related disorder from 70 percent to 50 percent effective August 1, 2020, and the Veteran submitted a VA Form 10182 (Notice of Disagreement) in May 2020. However, that appeal falls under the Appeals Modernization Act and thus, the issue of the propriety of that reduction is not properly before the Board at this time, and will be addressed by the Board in a separate Board decision. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. The percentage ratings are based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C. § 5107 (a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C. § 5107 (b). In general, the degree of impairment resulting from a disability is a factual determination and the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. §§ 4.3, 4.7. Otherwise, the lower rating will be assigned. Id. 1. Entitlement to a compensable rating for bilateral hearing loss Hearing loss is evaluated under DC 6100. Assignment of a disability rating for hearing loss is derived by a mechanical application of the rating schedule to the specific numeric designations assigned after audiology testing is completed. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Additionally, VA must analyze the functional effects caused by a hearing loss disability. See Martinak v. Nicholson, 21 Vet. App. 447 (2007). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. 38 C.F.R. § 4.85. The rating schedule establishes 11 auditory hearing acuity levels based upon average puretone thresholds and speech discrimination. See 38 C.F.R. § 4.85. “Puretone threshold average” as used in Tables VI and VIa is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz and divided by four. This average is used in all cases (including those of § 4.86) to determine a Roman numeral designation from Tables VI and VIa. 38 C.F.R. § 4.85(d). Table VI, “Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination,” is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the puretone threshold average (vertical columns). The Roman numeral designation is located at the point where the row and column intersect. 38 C.F.R. § 4.85(b). Table VIa, “Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average,” is used to determine a Roman numeral designation (I through XI) for hearing impairment based only on puretone threshold average. Table VIa is used when the examiner certifies that the use of the speech discrimination test is not appropriate due to language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of § 4.86. 38 C.F.R. § 4.85(c). Table VII, “Percentage Evaluations of Hearing Impairment,” is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment in each ear. The horizontal rows represent the ear having better hearing and the vertical columns represent the ear having the poorer hearing. The percentage evaluation is located at the point where the row and the column intersect. 38 C.F.R. § 4.85(e). Special provisions apply in instances of exceptional hearing loss. See 38 C.F.R. § 4.86. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) are all 55 decibels or more, the adjudicator must determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa in 38 C.F.R. § 4.85, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). Also, when the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear is evaluated separately. 38 C.F.R. § 4.86(b). The Veteran underwent a VA examination in September 2017 for his hearing loss. The results were as follows: HERTZ (dB) 1000 2000 3000 4000 Average RIGHT 20 30 70 85 51 LEFT 65 90 95 105 89 The VA examiner determined that the Veteran’s speech discrimination score using the Maryland CNC word list was 100 percent in the right ear and 98 percent in his left ear. The examiner indicated that use of the speech discrimination scores was appropriate for rating purposes. The examiner indicated that the Veteran’s hearing loss did not impact his ability to work. The Veteran was afforded another VA examination in November 2019 for his hearing loss. The results were as follows: HERTZ (dB) 1000 2000 3000 4000 Average RIGHT 15 30 70 85 50 The VA examiner indicated that puretone thresholds in decibels for the right ear could not be tested at 2000, 3000, or 4000 Hz, and no average could be determined. After testing 1000 Hz, the Veteran removed the headphones and stated “too loud,” so the examiner was unable to perform further testing. A speech discrimination score was not determined for the left ear. The examiner determined that the Veteran’s speech discrimination score using the Maryland CNC word list was 94 percent in the right ear. The examiner indicated that use of the speech discrimination scores for the right ear was appropriate for rating purposes. The examiner opined that the Veteran’s hearing loss did not impact his ability to work. Based on the evidence above, the Board finds that a compensable disability rating for bilateral hearing loss is not warranted. Applying Table VI to the Veteran’s September 2017 VA examination results, the Veteran had Level I hearing in the right ear. The Veteran had an exceptional hearing pattern in the left ear. Thus, applying Table VI, he would have Level III hearing in the left ear. According to Table VIa, he would have Level VIII hearing. Under 38 C.F.R. § 4.86(a), the higher numeral shall be used for exceptional hearing. Thus, Level VIII hearing will be applied for the left ear. Relying on this audiometric testing, with Level VIII hearing in the left ear and Level I hearing in the right ear, a noncompensable rating was warranted on this date. See Tables VI, VIa, VII. The Board has also considered the Veteran’s November 2019 VA examination, and finds that the objective testing does not warrant a compensable rating. Given the results provided for the right ear, which result in Level I acuity, the Board notes that Level X hearing would be required in the left ear in order to warrant a higher rating. There is no evidence in the record that the Veteran’s left ear hearing approached Level X during the appeal period. The Board acknowledges the Veteran’s statements that he lost hearing in his left ear. However, even after considering the functional impact of this disability, the evidence shows that a higher rating is not warranted. The Board gives the VA examinations significant weight, as they address all the rating criteria. See also Doucette v. Shulkin, 28 Vet. App. 366, 371-72 (2017) (difficulty in distinguishing sounds in a crowded environment, locating the source of sounds, understanding conversational speech, hearing the television, and using the telephone each are a manifestation of difficulty hearing or understanding speech, which is contemplated by the schedular rating criteria for hearing loss). Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 54-55. 2. Entitlement to a rating in excess of 70 percent for other specified trauma- and stressor-related disorder The Veteran’s PTSD is rated under 4.130, Diagnostic Code 9411. Under the General Formula for Mental Disorders (General Formula), 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). A 70 percent rating is provided 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is provided 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. VA shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). A veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the presence of the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-118 (Fed. Cir. 2013). In addition to requiring the presence of the enumerated symptoms, 38 C.F.R. § 4.130 also requires that those symptoms have caused the specified level of occupational and social impairment. Id. However, the factors listed in the rating schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating, so the determination should not be limited solely to whether a veteran exhibited the symptoms listed in the rating scheme, but should also be based on all of a veteran’s symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-443 (2002); 38 C.F.R. § 4.126(a). It is error where the Board fails to assess adequately evidence of a sign or symptom experienced by the veteran, misrepresents the meaning of a symptom, or fails to consider the impact of the veteran’s symptoms as a whole. However, the presence or lack of evidence of a specific sign or symptom listed in the evaluation criteria, including suicidal ideation, is not necessarily dispositive of any particular disability level. Bankhead v. Shulkin, 29 Vet. App. 10, 25 (2017). Turning to the evidence, the Veteran’s outpatient records show that in September 2016, he presented to a VA medical center (VAMC) emergency room with depression. He reported that he was worried about his wife’s cancer, and if she died, he might consider hurting himself. The Veteran denied feeling acute suicidal ideation. The Veteran reported that he felt close to his daughter and grandson. The Veteran was anxious and had disturbed sleep with nightmares. He denied anhedonia, delusions, and hallucinations, and was frustrated, but cooperative and engaged. The Veteran had normal speech, was future-oriented, and had linear and organized thoughts. He was assessed as being at low risk of harm to himself and was safe for discharge. The Veteran sought to establish outpatient mental health treatment in September 2016. He reported that he had moved for his wife’s cancer treatment and to be closer to their daughter. The Veteran presented with anxious mood, and appeared reactive and guarded. His trauma symptoms included avoidance, isolation, anger, insomnia, and hypervigilance. He denied suicidal ideation, paranoia, delusions, and hallucinations. His judgment and impulse control were good. The Veteran had adequate hygiene, he maintained good eye contact, and had normal speech and logical and coherent thoughts. The Veteran had an appointment in December 2016. At the appointment, he had appropriate grooming, consistent eye contact, normal speech, and logical thoughts. The Veteran had limited affect, and insight and judgment were good. The Veteran did not report suicidal ideation, paranoia, or hallucinations. The Veteran’s trauma symptoms were not fully addressed, as the Veteran reported mistrust. The Veteran attended appointments in January 2017, February 2017, March 2017, May 2017, July 2017, and August 2017. His trauma symptoms were not directly discussed or addressed at any appointment, as the Veteran reported mistrust, and the Veteran discussed his wife’s health and his adjustment to the move. The Veteran was not noted to have hallucinations, delusions, illogical thoughts, disorientation, communication impairments, inappropriate behavior, memory loss, or be in danger of hurting himself. The Veteran underwent a VA examination in September 2017. The examiner diagnosed the Veteran with other specified trauma- and stressor-related disorder and adjustment disorder with anxious mood. The Veteran’s anxiety was attributable to adjustment disorder, and sleep impairment and inability to establish and maintain relationships were attributable to trauma-related disorder, but all of the Veteran’s impairment was attributable to the trauma-related disorder. The Veteran denied delusions, hallucinations, paranoia, and panic attacks. He reported mood and anxiety symptoms related to his wife. The Veteran’s thoughts were logical, coherent, rational, and organized. In December 2017, the Veteran sought treatment at a VAMC. He reported that he was feeling “more stressed” and wanted to reestablish care. The Veteran was scheduled for an appointment in January 2018, at which time he was evaluated. The Veteran reported passive suicidal ideation, but had protective factors such as his relationships with his wife, being future-oriented, and expressing hope. He also reported “horrible” sleep and had depressed mood. During the evaluation, the Veteran was alert and oriented, and had appropriate affect. The Veteran had appointments in February 2018, March 2018, and April 2018. He had appropriate grooming, and was alert and oriented at all appointments. The Veteran engaged with the provider, had appropriate affect, and no speech or memory impairments were noted. In May 2018, June 2018, and August 2018, the Veteran was noted to have had adequate grooming, fair eye contact, insight, and judgment, normal speech, and organized thoughts. The Veteran was oriented and cooperative, and did not express delusions. The Veteran was seen again in June 2019. The clinic note indicates that he had not been seen in approximately one year. The Veteran reported that his life was “falling apart” because of his wife’s health. He reported nightmares, and requested a prescription refill. The Veteran declined additional treatment. The Veteran was minimally cooperative, argumentative, and resistant. Mood was dysphoric. Speech was within normal limits, grooming was adequate, eye contact, insight, and judgment were fair. The Veteran was oriented and did not express suicidal ideation, delusions, or hallucinations. In August 2019, the Veteran completed an assessment with Dr. H. H.-G. She completed a Disability Benefits Questionnaire (DBQ) and wrote an evaluation report. Dr. H.-G. diagnosed the Veteran with other specified trauma- and stressor-related disorder. The Veteran lived with his wife, but was socially isolated and withdrawn. He reported seeing a psychiatrist annually, and denied seeing a therapist. The Veteran’s symptoms as documented in the DBQ included anxiety, suspiciousness, panic attacks more than once per week, near-continuous panic or depression, chronic sleep impairment, flattened affect, disturbances of motivation and mood, inability to establish and maintain effective relationships, difficulty adapting to stressful circumstances, suicidal ideation, and delusions or hallucinations. He did not have memory loss, speech impairments, difficulty understanding complex commands, impaired judgment or abstract thinking, impaired thought processes, impaired impulse controls, spatial disorientation, grossly inappropriate behavior, persistent danger of hurting self, neglect of hygiene, intermittent inability to perform activities of daily living, or disorientation to time or place. The Veteran managed household finances. In the report, Dr. H.-G. explained that the Veteran performed the majority of his daily living tasks, including food shopping, meal preparation, showers, and household chores. She reported that the Veteran’s severity of symptoms was the same as from the date of his claim. The Veteran indicated that he heard noises and saw figures, and had insomnia, broken sleep, and nightmares. His symptoms also included anhedonia, concentration issues, emotional lability, fatigue, irritability, and a feeling of helplessness and hopelessness. The Veteran had another VA examination in October 2019. He was diagnosed with PTSD and adjustment disorder with depressed mood. The examiner explained that the adjustment disorder diagnosis was related to the Veteran’s life changes, including his wife’s cancer diagnosis and treatment, relocating, retirement, and financial issues. The PTSD caused symptoms such as reexperiencing trauma, intrusive distressing memories, feelings of detachment or estrangement, hypervigilance, sleep disturbance, arousal, and avoidance. The symptoms associated with adjustment disorder were depressed mood and irritability. The Veteran’s symptoms also included suspiciousness, anxiety, sleep impairment, paranoia, and difficulty establishing relationships. At the examination, the Veteran had no delusions, hallucinations, or suicidal ideation. The examiner explained that there was overlap among the symptoms of adjustment disorder and PTSD, and it was likely that each disorder exacerbated the other. In May 2020, articles related to PTSD were submitted in support of the Veteran’s claim. In November 2020, the Veteran’s wife submitted a statement. She explained that the Veteran experienced nightmares, and they slept in separate rooms because the Veteran had grabbed her in his sleep. The Veteran was also anxious, jumpy, easily startled, and socially withdrawn. The Veteran also submitted a statement in November 2020. He explained that it was difficult for him to trust others or be around people. The Veteran reported trouble sleeping, panic attacks, worrying about someone breaking into his house, nightmares, and suicidal ideation. Having reviewed the evidence, the Board concludes that for the entire appeal period, including from August 1, 2020, a 70 percent rating for trauma-related disorder is warranted. In November 2020, the Veteran and his wife reported symptoms that warrant a 70 percent rating, including suicidal ideation, nightmares, social isolation, sleep impairments, and panic attacks. These symptoms represent deficiencies in most areas of life, including work, family relations, judgment, thinking, and mood. Therefore, a 70 percent rating shall be assigned for the appeal period. However, the Board also concludes that a 100 percent rating is not warranted for the Veteran’s trauma-related disorder as total social and occupational impairment is not shown or more nearly approximated. The Veteran maintained an ability to identify and report problems to his treatment providers and cooperate with them, which indicates he did not have a total social impairment. The Veteran also maintained a relationship with his wife and daughter. The Veteran was always coherent, and oriented to time and place, and did not have major memory loss, such as forgetting his own name. There is no evidence in the record of an inability to perform activities of daily living, such as maintaining minimal hygiene. In fact, the August 2019 evaluation report indicated the contrary, that the Veteran showered, paid bills, prepared meals, and grocery shopped. Moreover, the Veteran did not exhibit grossly inappropriate behavior or persistent danger to self or others. While the Board acknowledges that the Veteran and his wife reported that his symptoms worsened, such as hallucinations, the evidence does not support a finding that the Veteran’s trauma-related symptoms totally impaired the Veteran’s functioning. As the Veteran’s symptoms of nightmares, irritability, hyperarousal, anxiety, intrusive thoughts, depressed mood, sleep impairment, disturbances of motivation, difficulty maintaining effective relationships, and suicidal ideation are contemplated by a 70 percent rating, a 100 percent rating is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the claim, and the claim for a rating in excess of 70 percent is denied. Thus, a 70 percent rating is warranted for the entire appeal period. 3. Entitlement to a total disability rating based on individual unemployability Total disability is considered to exist when there is any impairment in mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (a)(1). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability, that is, 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. 38 C.F.R. § 4.16 (a). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). See also Faust v. West, 13 Vet. App. 342 (2000). The United States Court of Appeals for Veterans Claims (Court) has held the phrase "substantially gainful employment" has an economic component and a non-economic component. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). "The economic component simply means 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." Id. The noneconomic component goes to the veteran's individualized ability to secure and follow substantially gainful employment. Ray, 31 Vet. App. at 73. Attention must be given to the veteran's history, education, skill, and training; whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy); and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Id. The ultimate determination of whether a Veteran is capable of substantial gainful employment rests with the VA adjudicator, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (citing 38 U.S.C. § 5103A (d)(1)) (the VA adjudicator has the ultimate responsibility for a TDIU determination and VA is not required in every case to obtain a single medical opinion regarding the combined impact of all service-connected disabilities). If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. Individual unemployability must be determined without regard to any non-service connected disabilities or the Veteran’s advancing age. 38 C.F.R. §§ 3.341 (a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In reaching a determination of TDIU, it is necessary that the record reflect some factor which takes the Veteran’s case outside the norm with respect to a similar level of disability under the rating schedule. 38 C.F.R. §§ 4.1, 4.15; Van Hoose, 4 Vet. App. at 363. The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Beaty v. Brown, 6 Vet. App. 532, 538 (1994). A rating decision code sheet shows that the Veteran is service-connected for: trauma- or stressor-related disorder, rated at 70 percent disabling prior to August 1, 2020; tinnitus, rated at 10 percent from May 26, 2015; and bilateral hearing loss, rated as noncompensable from May 26, 2015. Prior to August 1, 2020, the Veteran’s combined rating was 70 percent. The Board has also concluded that a 70 percent rating is warranted for the Veteran’s trauma-related disorder for the entire appeal period. Therefore, for the entire appeal period, the Veteran’s meets the schedular criteria for a TDIU. The question, then, is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his other specified trauma- and stressor-related disorder, tinnitus, and hearing loss. As explained in greater detail below, the Board concludes that the Veteran’s service-connected disabilities render him unable to secure or follow a substantially gainful occupation. Turning to the evidence, the Board notes that the Veteran underwent a VA examination for hearing loss in September 2017. The examiner opined that the Veteran’s tinnitus and hearing loss did not impact his ability to work. The Veteran’s VAMC records indicate that he had been living and working as a fisherman on an island in Alaska. When the Veteran moved, he lost his primary means of coping with trauma symptoms, which was avoidance through work. The Veteran underwent a VA examination for his mental health in September 2017. The examiner opined that the Veteran’s stress-related disorder caused occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran reported that he sold his commercial fishing business in May 2015 because he could no longer work safely due to age, loss of night vision, and hearing loss, which made him a danger to other people on the job. In addition, the examiner opined that the Veteran’s abilities to understand and follow instructions, retain instructions, sustain concentration to perform simple tasks, sustain concentration to task persistence and pace, and impulse control were not impaired. The Veteran’s ability to respond appropriately to coworkers, supervisors, or the general public was moderately impaired. His abilities to accept supervision and criticism, and be flexible in the work setting were markedly impaired. Finally, his ability to work in groups was profoundly impaired. At an outpatient appointment in June 2018, the Veteran reported that he worked as a fisherman because he was unable to be around people. The clinic note reflects that the Veteran sold his business in order to move closer to family for his wife’s cancer treatment. The Veteran spent a year in junior college studying writing and biology. In August 2019, Dr. H. H.-G. completed a Functional Capacity Evaluation and wrote an evaluation report. She indicated that the Veteran would miss or leave early more than three days a month due to mental problems. Additionally, the Veteran would not stay focused for at least seven hours more than three days a month. If the Veteran were subjected to normal pressures of a job, he would respond inappropriately more than once per month, and he would become angry but not violent. She explained that he could not sustain the stress from a work environment or be expected to engage in gainful activity due to symptoms such as sleep impairment, fatigue, difficulty maintaining mood, lack of concentration, suspiciousness, anxiety, poor interpersonal skills, and suicidal ideation. Dr. H.-G. explained that the Veteran could present a safety hazard and exhibit behavior that could be inappropriate in a job setting. The Veteran had a VA examination in October 2019. The examiner opined that the Veteran’s trauma-related disorder caused occupational and social impairment with reduced reliability and productivity. The Veteran reported that he sold his business because he was unable to act safely due to vision and hearing problems. The Veteran was afforded a VA examination for hearing loss in November 2019. The examiner opined that the Veteran’s tinnitus and hearing loss did not impact his ability to work. The Veteran submitted a statement in November 2020, in which he explained that his insomnia led to safety problems while he was working as a fisherman. The Veteran also reported that he had tried to find another job, and had mowed lawns, but he was unable to have a client, work with people, or have a boss. In November 2020, the Veteran’s wife wrote that the Veteran used to hire deckhands and sell fish. However, the Veteran became paranoid and thought he was going to die on the water, so he quit. After reviewing the evidence, the Board concludes that a TDIU is warranted. While there is some evidence against the Veteran’s claim, namely the VA examination conclusions in September 2017 and November 2019 that the Veteran’s tinnitus and hearing loss do not impact his ability to work, the Board finds that the Veteran’s trauma-related symptoms prevent him from following substantially gainful employment. The Veteran’s psychiatric disorder causes social isolation, anger and irritability, fatigue, anxiety, paranoia, lack of concentration, and interpersonal problems. Moreover, Dr. H.-G. opined, with explanation, that the Veteran was unable to maintain gainful employment, and the September 2017 VA examiner indicated some profound, marked, and moderate occupational limitations caused by his mental health symptoms. There is no evidence in the file that the Veteran has qualifications or experience that would allow him to work in an any other isolated job or in a job where he did not have to get along with a boss, supervisors, customers, the public, or coworkers. Therefore, the Board concludes that a grant of the Veteran’s TDIU claim is warranted. 4. Entitlement to special monthly compensation based on aid and attendance allowance for a dependent spouse A veteran who is entitled to compensation, and whose disability is rated not less than 30 percent, shall be entitled to additional compensation for dependents, including a spouse. 38 U.S.C. § 1115; 38 C.F.R. § 3.4 (b)(2). Increased compensation is payable to a veteran by reason of the Veteran’s spouse being in need of aid and attendance. 38 C.F.R. § 3.351 (a)(2). A spouse will be considered in need of regular aid and attendance if he or she is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to five degrees or less; is a patient in a nursing home because of mental or physical incapacity; or establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352 (a). See 38 U.S.C. § 1502 (b); 38 C.F.R. § 3.351 (c). Under 38 C.F.R. § 3.352 (a), the following factors will be accorded consideration in determining whether the claimant is in need of regular aid and attendance of another person: (1) inability of the claimant to dress or undress himself/herself, or to keep himself/herself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; (3) inability of the claimant to feed himself/herself because of the loss of coordination of upper extremities or because of extreme weakness; (4) inability to attend to the wants of nature; or (5) physical or mental incapacity which requires care or assistance on a regular basis to protect the claimant from the hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352 (a). For the purposes of 38 C.F.R. § 3.352 (a), “bedridden” will be a proper basis for the determination of whether the claimant is in need of regular aid and attendance of another person. “Bedridden” will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352 (a). It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352 (a) be found to exist before a favorable rating may be made. See Turco v. Brown, 9 Vet. App. 222, 224 (1996) (holding that at least one factor listed in § 3.352(a) must be present to grant special monthly compensation based on the need for aid and attendance). The particular personal functions that the claimant is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the claimant is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the claimant is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant’s condition is such as would require him or her to be in bed. They must be based on the actual requirements of personal assistance from others. 38 C.F.R. § 3.352 (a). The performance of the necessary aid and attendance service by a relative of the beneficiary or other member of his or her household will not prevent the granting of the additional allowance. 38 C.F.R. § 3.352 (c). The Veteran asserts that an aid and attendance allowance is warranted because his spouse had surgery and underwent chemotherapy and radiation therapy. The Veteran’s outpatient records indicate that in January 2017, February 2017, March 2017, May 2017, and July 2017, the Veteran discussed his move for his wife’s treatment, and her being “nitpicking” and “demanding.” He was experiencing stress and anxiety related to her diagnosis and treatment. In November 2017, the Veteran reported she was doing well following her radiation. In April 2018, the Veteran reported that his wife was no longer experiencing “a fog” and was handling finances. In May 2018, the Veteran indicated that his wife was in recovery and “doing much better.” In July 2018, the Veteran reported that his wife was doing “okay” and no longer had cancer. After reviewing the evidence of record, the Board finds that the weight of the evidence indicates that the Veteran’s spouse does not meet the criteria for aid and attendance. First, the evidence does not establish aid and attendance based on the Veteran’s spouse’s visual acuity or being in a nursing home. Second, with respect to a factual need for aid and attendance, the evidence does not show, nor has the Veteran asserted that the Veteran’s wife was bedridden, unable to dress herself or keep herself clean and presentable, or unable to feed herself because of loss of coordination or extreme weakness in her upper extremities. The record also does not demonstrate that the Veteran’s wife had an inability to attend to the wants of nature or had physical incapacity to protect herself from the dangers of her environment. Accordingly, the criteria for an aid and attendance for the Veteran’s spouse have not been met. The Board acknowledges the Veteran’s reports that he had been “caring” for his wife and was her “caretaker.” However, without more, the Board finds that there is not a preponderance of evidence to establish that the Veteran’s wife was “so helpless” as to warrant additional compensation. Notwithstanding the Veteran’s assertions, the record does not contain medical evidence regarding the nature of his spouse’s physical limitations.   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 v. Derwinski, 1 Vet. App. 49, 53. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Smith, 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.