Citation Nr: 21009920 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 14-37 406 DATE: February 23, 2021 THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent prior to November 3, 2016 and 50 percent thereafter for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to special monthly compensation (SMC) for aid and attendance or housebound status. ORDER 1. Entitlement to a disability rating in excess of 30 percent prior to November 3, 2016 and 50 percent thereafter for service-connected posttraumatic stress disorder (PTSD) is denied. 2. Entitlement to SMC for aid and attendance or housebound status is denied. FINDINGS OF FACT 1. For the period prior to November 3, 2016, the Veteran’s service-connected PTSD resulted in no worse than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). Occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, or total occupational and social impairment were not shown. 2. As of November 3, 2016, the Veteran’s service-connected PTSD has resulted in no worse than occupational and social impairment with reduced reliability and productivity. Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, or total occupational and social impairment were not shown. It was not factually ascertainable prior to such time that an increase in disability had occurred. 3. The Veteran does not require regular aid and attendance nor is he factually housebound due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 30 percent prior to November 3, 2016 and 50 percent thereafter for service-connected PTSD have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.126, 4.130, Diagnostic Code 9411 (2020). 2. The criteria for SMC for aid and attendance and housebound benefits have not been met or approximated. 38 U.S.C. §§ 1114, 5107 (2012); 38 C.F.R. §§ 3.352, 3.350 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty with the United States Air Force from September 1964 to September 1985, to include service in the Republic of Vietnam. This case is before the Board of Veterans’ Appeals (Board) on appeal from a February 2011 rating decision by the Regional Office (RO) in Montgomery, Alabama. In a May 2018 decision, the Board denied the Veteran’s claim for an increased disability rating for service-connected PTSD. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (CAVC or Court). While his claim was pending at the Court, the Veteran’s representative and the VA Office of General Counsel filed a Joint Motion (JMR) requesting that the Court vacate the Board’s decision and remand the case to the Board for further development and re-adjudication. In a February 2019 Order, the Court granted the Joint Motion, and the case was returned to the Board. Specifically, the JMR found that the Board did not adequately explain its rationale in the May 2018 decision. In a November 2019 decision, the Board again denied the Veteran’s claim for an increased disability rating for service-connected PTSD and also denied his claim for entitlement to SMC. The Veteran appealed the decision to CAVC. While his claim was pending at the Court, the Veteran’s representative and the VA Office of General Counsel filed a Joint Motion (JMR) requesting that the Court vacate the Board’s decision and remand the case to the Board for further development and re-adjudication. In a September 2020 Order, the Court granted the Joint Motion, and the case was returned to the Board. Specifically, the JMR found that the Veteran had submitted an extension request, which the Board did not respond to, and that the Board did not adequately explain its rationale in the November 2019 decision. The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). 1. Entitlement to a disability rating in excess of 30 percent prior to November 3, 2016 and 50 percent thereafter for service-connected PTSD. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. When 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. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Where the question for consideration is the propriety of the initial ratings assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA’s adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. A Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that it discuss, in exhaustive detail, each and every piece of evidence he submitted or that VA has obtained on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each and every piece of evidence). Rather, the Board’s analysis focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000) (the law requires only that the Board discuss its reasons for rejecting evidence favorable to him). 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. The Veteran asserts that he is entitled to higher disability ratings than currently assigned for his service-connected PTSD, evaluated as 30 percent disabling prior to November 3, 2016 and 50 percent disabling thereafter. By way of background, in a February 2011 rating decision, the RO granted the Veteran’s claim for service connection for PTSD and issued a 30 percent disability rating effective May 12, 2010. Later, in a November 2016 rating decision, the RO increased the Veteran’s rating to 50 percent disabling effective November 3, 2016. Under VA’s General Rating Formula for Mental Disorders, a 10 percent rating is warranted where the disorder is manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 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); and inability to establish and maintain effective relationships. The maximum 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; and memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Further, simply because the Veteran has some symptoms that are contemplated at a higher rating level does not mean the impact of his PTSD overall rises that level. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Instead, the Board must look to the frequency, severity, and duration of the impairment. Disability rating prior to November 3, 2016 As noted by the September 2020 JMR, a May 2010 VA treatment record described the Veteran as down, depressed, or hopeless” several days per week. The Veteran was afforded a VA examination in connection with his claim in January 2011. The Veteran reported that he started experiencing psychiatric problems about two and a half years prior. He reported intrusive thoughts of his experience in Vietnam, significant problems sleeping, and nightmares two to three times per week which would cause him to wake up “hollering and screaming.” He indicated that when his PTSD symptoms were at their most severe level, he experienced suicidal ideation, but had not made any attempts. The Veteran indicated that these episodes of suicidal ideation, of which there were two or three, were in the past and had not reoccurred since he sought psychiatric treatment in April of 2009. He denied any current suicidal ideation and denied ever having homicidal ideations. The Veteran reported that he first sought treatment at the VA in November 2007, and that his mother had also helped him with his PTSD symptoms by counseling him and praying with him. The Veteran stated that this helped improve his symptoms. The Veteran described his first marriage as ending after 10 years “because his wife became an alcoholic” and his second marriage ending after 10 years because “they had multiple disagreements and the [Veteran] reports that she spent all his money as well as the money she made.” Finally, the Veteran noted that his current marriage had lasted 12 years and that the marriage “has been pretty good.” The Veteran reported intrusive thoughts of Vietnam approximately once per week. He stated that he avoids talking or thinking about Vietnam, and also avoids watching war movies and the news. He reported experiencing only minor alienation from others, nothing that he is not as social as he used to be and avoids crowds. The Veteran also reported hypervigilance and a hyperactive startle reflex. He described some irritability and “snapping” at his wife a couple of times per week. The Veteran denied problems with depression. On mental status examination, the Veteran was noted to be casually dressed with adequate grooming. He was polite and cooperative throughout the examination, with good eye contact and rapport with the examiner. His speech was clear, coherent, and relevant. There was no evidence of psychosis, hallucinations, or thought disorder. The Veteran’s immediate memory was intact, although he had mild difficulty with short term memory. Long term memory appeared intact, and abstract thinking was essentially intact. Overall, the examiner concluded that the Veteran’s PTSD symptoms had a relatively minor impact on his life, they did not appear to interfere with his occupation, and only mildly impacted his family and social relationships. The examiner described the Veteran’s PTSD symptoms as being in “partial remission.” In a February 2012 notice of disagreement (NOD), the Veteran stated that his PTSD caused problems sleeping, which impacted his quality of life. VA treatment records include a negative PTSD screen in February 2012. Later, in September 2014, the Veteran was afforded a VA primary care behavioral health initial evaluation. At the outset, the Veteran denied suicidal or homicidal ideation, plan, or intent. The Veteran expressed concern related to problems with sleep and irritability. He reported difficulty staying asleep due to frequent “bad dreams,” and his wife reported that the Veteran yells and tosses and turns in his sleep. The Veteran acknowledged being quick tempered and “snappy” toward his wife, resulting in frequent arguments. See also September 2020 JMR. In a September 2014 letter, (that appears to have been mistakenly cited as a September 2015 letter in the February 2019 JMR- see below**), the Veteran’s wife wrote that the Veteran’s PTSD causes him to become irate and angry for no reason, “and when he is not irate, he is depressed.” She wrote that he also experiences panic attacks during which “he feels someone is trying or going to kill him.” She wrote that he constantly wakes her up at night with his moaning and screaming, causing them to sometimes sleep in different rooms. She suggested that the Veteran’s judgment is impaired, which causes him to become disturbed. She also noted increased social isolation and avoidance. the Veteran’s wife wrote that she was “taking over his affairs because he forgets to do many things.” The Veteran’s wife noted that the Veteran would forget to return mail. A September 2014 VA Nursing note stated that the Veteran’s wife visited a VA facility to voice concerns about the Veteran’s mood swings, depression, and social isolation. The Veteran’s wife alleged that the Veteran’s PTSD symptoms were worse than the Veteran portrayed outside the home. An October 2014 VA individual treatment note indicated an improvement in the Veteran’s mood since his previous visit. Specifically, the Veteran reported feeling less angry and sad, which he attributed to increased prayer and talking with friends. The Veteran continued to report sleep trouble, waking up two to three times a night, two to three times per week due to dreams of Vietnam. The Veteran and his wife both reported frequent arguments. **The Board notes that the February 2019 JMR refers to the above mentioned letter as a September 2015 correspondence. The Board has made its best judgement as to what evidence the February 2019 JMR was referencing, and finds that that letter cited in the 2019 JMR is in fact the September 2014 letter described above. The Veteran participated in PTSD group therapy on a weekly basis at VA in 2015. A January 2015 group therapy note indicated that the Veteran’s nightmares were impacting his wife’s sleep. In a subsequent January 2015 group therapy note, the Veteran reported “no problems” during the previous week. In February 2015, the Veteran reported a bad nightmare, which he preferred not to discuss. The Veteran later reported spending time working on his truck, which he found both productive and enjoyable. In an April 2016 VA treatment note, the Veteran reported that “overall he is doing well.” In a May 2016 letter, the Veteran’s wife noted that the Veteran “cannot control his emotions and he goes off from high to low at a drop of a hat.” In a May 2016 VA mental status examination, the Veteran appeared well groomed and casually dressed. His speech was somewhat limited, though he responded to direct questions. The examiner noted no abnormalities in volume, prosody, or rate of speech. Eye contact and behavior were appropriate; cooperation was adequate; and thought processes were linear and devoid of psychotic features. He was found to be oriented to person, place, and time and his recent and remote memory was intact. The Veteran denied paranoia, visual hallucinations, auditory hallucinations, and suicidal or homicidal ideation. In a May 2016 statement in support of claim, the Veteran reported that he finished “Track II” of his PTSD classes and was pending start of the third phase. He also wrote, “I am unable to cope with things and my whole demeanor is not pleasant.” In a June 2016 letter, the Veteran’s wife wrote that the Veteran was still struggling with his PTSD symptoms. She wrote that he “pretends to make himself act and look ok when he is outside home so people will not notice he has a problem.” She wrote that his nighttime screaming and restlessness causes her to have to sleep in a different room. She wrote that he pretends he is fine but really, “he cannot control his emotions.” She called into question his judgment, describing how he constantly makes bad financial decisions and has friends who have a bad influence on his mindset. She noted that the Veteran exhibits increased agitation and paranoia around large crowds. The Veteran was afforded another VA examination in June 2016, during which he reported a problematic relationship with his wife. He reported that he is short-tempered, and that he sometimes sleeps in a different room because he worries he will accidentally hurt his wife if he has a bad dream. The examiner found that the Veteran exhibited symptoms of recurrent, involuntary, and intrusive distressing memories of his PTSD stressor, as well recurrent distressing dreams and intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The examiner also found symptoms associated with persistent avoidance, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity. Under the symptoms section, the VA examiner only noted chronic sleep impairment. On mental status examination, the Veteran was found to be appropriately groomed and casually dressed; cooperative; and oriented to person, place, and time. He was cooperative and exhibited eye contact and psychomotor activity within normal limits. He did not appear anxious but reported occasional intrusive thoughts, increased startle reactions, and hypervigilance. His thought content did not demonstrate evidence of delusions or hallucinations, and his memory appeared to be within normal limits. His insight and judgment appeared to be intact, and he denied suicidal or homicidal ideations. He reported no problems carrying out his activities of daily living (ADLs). The examiner concluded that the Veteran’s PTSD symptoms led to occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran submitted a letter dated July 2019, but received by VA in October 2019 (hereinafter referred to as the October 2019 letter), describing past symptoms of PTSD, in which he claimed to suffer crippling depression “at least four days out of the week” and described trouble getting out of bed in the morning. The Veteran described going “days without showering or changing [his] clothes, because [he] simply did not care and lacked the motivation to do so.” The Veteran noted that his anxiety prevented him from going to areas with large groups of people, including stores, and that he leaves his house “once or twice [a week] for a doctors’ appointment.” The Veteran described hypervigilance, anger, difficulty sleeping. However, the Board notes that the time periods that the Veteran is referring to are unclear. Affording the Veteran the benefit of the doubt, the Board finds that the Veteran is attributing the above mentioned symptoms to both periods on appeal. While the Veteran notes that he suffered from suicidal ideation in the past, he reported a decline in their frequency since 2007, but noted “I still got thoughts of suicide from time to time.” The Board specifically notes that the Veteran’s wife alleged that the Veteran exhibits impaired judgment, social isolation, and impulse control, in addition to other symptoms. While the Board finds that the Veteran’s wife is competent to describe certain aspects of the Veteran’s behavior, the Board finds the medical evidence more probative. In reaching this conclusion, the Board notes that the medical examiners have specific expertise in recognizing and appropriately and objectively describing symptoms such as impaired judgment, social isolation, and impulse control. Both the January 2011 and June 2016 VA examinations were performed by mental health experts who, after a complete review of the record, found that the Veteran did not exhibit behavior serious enough to constitute impairment of impulse control, or judgement. The Board also considers that the January 2011 VA examiner found that the Veterans social isolation was mild in nature. The Board finds, therefore, that the VA examinations are more probative than the Veteran’s wife’s statements, as they were conducted by mental health professionals who have specific expertise and experience in describing psychiatric symptoms. Additionally, while the Veteran reported some suicidal thoughts in the October 2019 letter, he did not report such thoughts to any of the VA examiners. Indeed, the Veteran denied suicidal ideation several times in the medical record. See September 2016 VA treatment note; May 2016 VA treatment note; April 2016 VA treatment note; December 2015 VA treatment note. Therefore, the Board finds the Veteran’s consistent statements to the VA examiners more probative than the October 2019 letter. In the same vein, the Board has considered that the Veteran’s PTSD has impacted his family and social relationships. Specifically, the Board acknowledges the Veteran’s and his wife’s contentions that his PTSD symptoms affect the Veteran’s family relationships. However, the Board notes that they have had an ongoing and successful relationship for the entire period. The Veteran explained these symptoms to the June 2016 a medical examiner who has specific expertise in recognizing and appropriately and objectively describing symptoms such as difficulty in establishing and maintaining effective work and social relationships. While the Veteran later claimed that his previous marriages ended because of his PTSD symptoms in the October 2019 letter, the Veteran reported in his January 2011 VA examination that his previous marriages ended for reasons not to do with his PTSD symptoms. Therefore, the Board finds that this does not rise to the level of “difficulty in establishing and maintaining effective work and social relationships.” Finally, the Board acknowledges the Veteran’s claimed memory problems. Specifically, the Veteran and his wife claimed in affidavits received by VA in December 2020 that he frequently forgot to complete tasks. However, upon professional, medical evaluation, the Veteran’s memory problems were not described as “impairment of short- and long-term memory (including to complete tasks).” Indeed, his memory was described as “intact” and “within normal limits” by the above-mentioned VA examiners. The Board affords the medical evidence, particularly the contemporaneous VA examination reports which were conducted by medical professionals, more probative weight than the Veteran’s subsequent claims of memory problems described in the December 2020 affidavits. Finally, the Board has considered issue of whether the Veteran’s feeling depressed and irritable could be considered to rise to the level of “disturbances in motivation and mood,” as raised by the September 2020 JMR. See May 2010 VA treatment note; September 2014 VA treatment note. However, for the same reasons, the Board affords more weight to the VA examiners, who reviewed the entire claims file and each independently indicated that the Veteran’s irritability and depressed mood did not rise to the level of “disturbances in motivation and mood.” Overall, for the period prior to November 3, 2016, the Board finds that the competent and credible medical evidence consistently details signs and symptoms most closely associated with the currently assigned 30 percent disability rating. Throughout the period, the Veteran’s service-connected PTSD was primarily manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to his PTSD symptoms. The evidence shows that while the Veteran has experienced problems primarily with sleep disturbance, irritability, depressed mood, and social isolation, although he has generally been functioning satisfactorily. His conversation and behavior have been normal. The evidence does not show that he has 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; impaired judgment; or impaired abstract thinking. The frequency, severity, and duration of the Veteran’s current symptoms, noted above, have not risen to or approximated an evaluation of 50 percent for this period. As previously discussed, in order to warrant an evaluation of 50 percent for this period, the Veteran would have to be found to have 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. Based on the evidence set forth above, the Board does not find that these criteria have been met, and finds that a 30 percent rating more appropriately captures the Veteran’s disability picture for the period, based on the frequency, severity, and duration of the Veteran’s impairment. In making its determination, the Board has carefully considered the Veteran and his wife’s contentions with respect to the nature of his PTSD and notes that they are competent to describe certain associated symptomatology. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above. Ultimately, however, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the Veteran’s PTSD, because of the reasons discussed above. As such, while the Board accepts the Veteran and his wife’s lay testimony with regard to the matters they are competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. Therefore, based on the foregoing, the Board finds that a higher initial disability rating for the Veteran’s service-connected PTSD for the period prior to November 3, 2016 is not warranted. The Board has also considered whether the Veteran is entitled to an “earlier effective date” prior to November 3, 2016 for the grant of an increased disability rating for PTSD, as noted in the September 2020 JMR. The Board finds that the evidence does not clearly show that the Veteran’s disability picture had increased prior to the November 3, 2016 VA examination, based on the noted pattern of symptomatology above. See 38 C.F.R. § 3.400(o)(1) (If an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose)). Additionally, the Board observes that the Veteran’s contention that he be assigned an earlier effective date is in fact a claim for a staged increased rating, which the Board has considered and rejected for the period prior to November 3, 2016, as noted above. Disability rating as of November 3, 2016 The Veteran was afforded another VA examination to determine the current level of severity of his PTSD in November 2016. The examiner found that the Veteran exhibited symptoms of recurrent, involuntary, and intrusive distressing memories of his PTSD stressor, as well recurrent distressing dreams and intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The examiner found symptoms associated with persistent avoidance, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity. Additionally, the examiner noted irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. However, the examiner did not indicate that the Veteran displayed unprovoked irritability with periods of violence. The examiner noted that the above symptoms caused “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” The examiner noted that the Veteran’s PTSD is manifested by symptoms of anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a worklike setting. The examiner did not provide the results of any mental status examination. The examiner concluded that the Veteran’s PTSD symptoms, which, as noted above, caused clinically significantly distress or impairment, result in occupational and social impairment with reduced reliability and productivity. The Veteran submitted a letter in October 2019 in which he claimed to suffer crippling depression “at least four days out of the week” and described trouble getting out of bed in the morning. The Veteran described going “days with showering or changing [his] clothes, because [he] simply did not care and lacked the motivation to do so.” The Veteran noted that his anxiety prevented him from going to areas with large groups of people, including stores, and that he leaves his house “once or twice [a week] for a doctors’ appointment.” The Veteran described hypervigilance, anger, difficulty sleeping. However, the Board notes that the time periods that the Veteran is referring to are unclear. Affording the Veteran the benefit of the doubt, the Board finds that the Veteran is attributing the above mentioned symptoms to both periods on appeal. While the Veteran notes that he suffered from suicidal ideation in the past, he reported a decline in their frequency since 2007, but noted “I still got thoughts of suicide from time to time.” Additionally, the Veteran reported episodes of anger but noted that he “always left verbal altercations before they became physical.” The Board notes that while the Veteran claims in his October 2019 letter that he has suicidal ideation “from time to time,” the Veteran did not report any such symptoms to the November 2016 examiner, nor is there any indication in the medical record that the Veteran currently suffers from suicidal ideation. Indeed, medical records continue to show a lack of suicidal ideation. See March 2019 VA treatment note; January 2019 VA treatment note; November 2018 VA treatment note; July 2018 treatment note; June 2017 treatment note. Additionally, the Board acknowledges the contentions by the Veteran and his wife in the above noted December 2020 affidavits that he had memory problems which affected his ability to complete tasks. Based on the foregoing, the Board finds that as of November 3, 2016, the date that it became factually ascertainable that the Veteran’s PTSD symptoms had worsened, the competent and credible medical evidence consistently details signs and symptoms most closely associated with the currently assigned 50 percent disability rating. During the November 2016 VA examination, the Veteran’s PTSD symptoms amounted to clinically significant distress or impairment that was found to result in occupational and social impairment with reduced reliability and productivity. The evidence does not show that 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; or neglect of personal appearance and hygiene. While he had difficulty establishing and maintaining effective work and social relationships, he was not noted to have an inability to establish and maintain such relationships to warrant a higher rating. Additionally, while the Veteran’s symptoms included unprovoked irritability, there were no periods of violence. As directed by the September 2020 JMR, the Board has considered whether the Veteran’s noted periods of “physical aggression toward people and objects” could be considered periods of violence. In this case, while the Veteran may have become physically upset and adopted a posture of intimidation or aggression toward others, in the Veteran’s own words, he “always left verbal altercations before they became violent.” Therefore, the evidence clearly shows that the Veteran did not engage in “violence” as contemplated by rating criteria. His anxiety, flattened affect, and disturbances of motivation and mood are contemplated in his current 50 percent rating. The Board notes that the severity, frequency, and duration of the Veteran current symptoms of anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting, do not rise to the level of or approximate a higher disability rating. Therefore, based on the foregoing, the Board finds that a higher disability rating for the Veteran’s service-connected PTSD for the period starting November 3, 2016 is not warranted. 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, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to SMC for aid and attendance or housebound status is denied. In this case, the Veteran contends that he is in need of regular aid and attendance of another person and that therefore SMC based on this need is warranted. SMC is payable under 38 U.S.C. § 1114 (l) if, as the result of service-connected disability, the Veteran is permanently bedridden or is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). Need for aid and attendance means being so helpless as to require the regular aid and attendance of another person. 38 C.F.R. § 3.350 (b). To establish this need, the evidence must show that that the Veteran is permanently bedridden or is so helpless as to be in need of regular aid and attendance as determined under criteria enumerated under 38 C.F.R. § 3.352 (a). First, “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). Here, the Veteran and the appellant have not contended, nor does the evidence show, that the claimant was bedridden by reason of his service-connected disabilities. For example, the evidence during the appeal period shows that the Veteran was able to move around the house with assistive devices and attend VA and private medical appointments. Thus, the evidence shows that the Veteran was not in need of aid and attendance by reason of being permanently bedridden. There need not be a constant need but, rather, only a regular need for aid and attendance. Id. It is not required that all of the disabling conditions are present or are due to a service-connected condition to warrant SMC. Id.; see also Turco v. Brown, 9 Vet. App. 222, 224 (1996). Under 38 C.F.R. § 3.352 (a), the following factors will be accorded consideration in determining whether the Veteran is in need of regular aid and attendance of another person: (1) inability of the Veteran to dress or undress himself, or to keep himself 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 Veteran to feed himself 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 Veteran from the hazards or dangers incident to his daily environment. 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. Further, the particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance not that there is a constant need for aid and attendance. 38 C.F.R. § 3.352 (a); 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 regulations also provide additional compensation on the basis of being housebound where the Veteran (1) has, in addition to a single, permanent service-connected disability rated 100 percent disabling, additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. A Veteran will be considered housebound where the evidence shows that, as a direct result of his service-connected disability or disabilities, he is substantially confined to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). In October 2018, The Veteran has filed a claim for SMC for aid and attendance and housebound benefits. During the entire period on appeal, the Veteran was service connected for a renal insufficiency, rated as 60 percent disabling. During the period on appeal prior to November 1, 2019, the Veteran was service connected for prostate cancer rated as 100 percent disabling and received SMC for housebound benefits. However, as of November 1, 2019, the Veteran’s service-connected prostate cancer has been rated as 10 percent disabling and SMC for housebound has been discontinued. The Veteran has also been service connected for psoriasis at a noncompensable disability rating, cataracts at a 10 percent disability rating, coronary artery disease at a 10 percent disability rating, hypertension at a 10 percent disability rating, diabetes mellitus type II at a 20 percent disability rating, and PTSD with a 50 percent disability rating for the entire period on appeal. As such, the Veteran, from November 1, 2019, does not meet the particular housebound benefits requirement of: in addition to a single, permanent service-connected disability rated 100 percent disabling, additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. The Veteran was afforded a VA aid and attendance or housebound examination in October 2018 in which he reported that he could not prepare his own meals. The examiner noted that the Veteran did not need assistance bathing or tending to other hygiene needs, was not legally blind, and did not require nursing home care. The examiner found that the Veteran was able to feed himself and was able to manage his own financial affairs. The examiner noted, however, that the Veteran required medication management. The Veteran required the use of an assistive device and his gait was shown to be abnormal due to a hip and knee disability. The Board notes that the Veteran has not been service connected for a hip or knee disability. The Veteran was noted to mostly say inside his home but that he left for doctors’ visits. Although medical records in September 2018 reveal the Veteran is sedentary, the examiner states that this is due to right hip discomfort, which is not service connected. See September 2018 VA treatment note. A February 2019 service treatment note also stated that the Veteran was “independent with all [activities of daily living] including driving.” The Veteran submitted a letter in October 2019 in which he claimed to suffer crippling depression “at least four days out of the week” and described trouble getting out of bed in the morning. The Veteran described going “days with showering or changing [his] clothes, because [he] simply did not care and lacked the motivation to do so. The Veteran noted that his anxiety prevented him from going to areas with large groups of people, including stores, and that he leaves his house “once or twice [a week] for a doctors’ appointment.” The Veteran described paranoia, anger, difficulty sleeping, and frequent trips to the bathroom. The Veteran also wrote that he needed help managing his medication and blood sugar. In affidavits received by VA in December 2020, but dated November 2019, the Veteran and his wife reiterated similar contentions. Specifically, the Veteran stated that due to PTSD, he forgot to eat, durn off the stove, and close the refrigerator door and that his wife had to help him with cooking meals, getting to doctor’s appointments, completing household chores, and managing medication. The Veteran wrote his renal insufficiency rendered him incontinent, which required him to wear Depends and also to forego driving. The Veteran also contended that his renal insufficiency caused a lot of pain in his hips and that therefore, his wife had to help him get out of bed in the mornings. Again, the Board notes that the Veteran has not been service connected for a hip disability. The Veteran also attributed dizziness and instability to his service-connected coronary artery disease, hypertension, and diabetes, noting that he required the use of a specialty device in his shower and that his wife would have to help wash him. The Veteran concluded by asserting his wife had to help him “almost 24 hours a day,” that he was only left alone for “about 3 to 4 hours” at a time, that he rarely left the house unless he had a doctor’s appointment, that he required assistance getting dressed, and that he mostly stayed on the couch in his den because it was hard for him to ambulate around the house without his wife due to instability. In a separate affidavit, the Veteran’s wife confirmed these details, adding that she scheduled doctor’s appointments for the Veteran and assists him entering and exiting the car. On review, the preponderance of the evidence is against a finding that the Veteran, during the period on appeal, was permanently bedridden or so helpless as to be in need of regular aid and attendance of another person due to his service-connected disabilities. While the Veteran required some day to day help from his wife, notably in the form of stabilization, this was in large part due to non-service-connected hip and knee disabilities, as clearly documented by the VA aid and attendance or housebound examination in October 2018. Additionally, while the Veteran, his wife, and his attorney contend that the Veteran needs near constant care in the form of scheduling medical appointments, cooking meals, medication management and assistance ambulating and dressing, the evidence simply does not show that due to his service-connected disabilities alone that he would be rendered permanently bedridden or so helpless as to be in need of regular aid and attendance. Therefore, entitlement to SMC based on aid and attendance is not warranted. The Board has also considered whether the Veteran qualifies for SMC based on being housebound. However, the Veteran already received SMC for housebound from the beginning of the appeal period to November 1, 2019, at which point his 100 percent disability rating for service-connected prostate cancer was reduced to 10 percent, and the Veteran no longer has a single disability rated at 100 percent, nor a TDIU based on a single disability. The Board also notes that the Veteran has been able to leave his household for doctor’s appointments, as noted above. Therefore, the Veteran is not entitled to SMC based on being housebound. Thus, the criteria for SMC aid and attendance and housebound benefits for the Veteran have not been met. 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 these claims, 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. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. E. Geary, 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.