Citation Nr: 21014404 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 10-21 194 DATE: March 12, 2021 ORDER Entitlement to an initial rating higher than 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance is denied. FINDINGS OF FACT 1. The Veteran’s PTSD has not manifested by total occupational and social impairment.  2. Resolving reasonable doubt in the Veteran’s favor, since March 24, 2009, the Veteran’s service-connected PTSD prevented him from obtaining and retaining substantially gainful employment consistent with his educational background and work experience. 3. The Veteran does not require the aid and assistance of another person due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 70 percent for PTSD with depressive disorder have not been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. From March 24, 2009, the criteria for the award of a TDIU have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 3. The criteria for special monthly compensation based on a need for aid and attendance have not been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1968 to December 1969. This case comes to the Board of Veterans’ Appeals (Board) from a May 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office. In a May 2017 Board decision, the Board granted a 70 percent initial rating for PTSD from February 11, 2012, but denied a rating higher than 70 percent and entitlement to a TDIU. The Veteran appealed the decision to the Court of Appeals for Veterans Claims (Court), and in November 2018, the Court vacated the Board’s denials. In October 2019, the Veteran’s attorney raised the issue of entitlement to special monthly compensation based on the need for aid and attendance, and in a January 2020 remand for further development, the Board added this issue to the current appeal, pursuant to Payne v. Wilkie, 31 Vet. App. 373 (2019). The Veteran appeared at a Travel Board hearing in October 2011. A transcript of that hearing is of record. In January 2017, VA informed the Veteran by letter that the Veterans Law Judge who conducted his October 2011 hearing was no longer employed by the Board. Later that month, the Veteran responded that he did not wish to have another hearing scheduled. PTSD The Veteran appeals the assignment of the 70 percent initial rating for PTSD, which has been effective from March 2, 2006. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity.  38 U.S.C. § 1155; 38 C.F.R. § 4.1.  Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating.  38 C.F.R. § 4.7. The Veteran’s service-connected PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411.  Psychiatric impairment is rated under the General Rating Formula for Mental Disorders.  This case was remanded by the Board in January 2014 and was pending before the Agency of Original Jurisdiction on August 4, 2014, and therefore the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-V) applies to this case. A 70 percent rating applies if the veteran has 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.  38 C.F.R. § 4.130, Diagnostic Code 9411.  A 100 percent rating applies if the veteran has 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.  Id.  Under 38 C.F.R. § 4.126(a), an evaluation of a mental disorder must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission.  The assigned rating should be 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.  While the evaluation should consider the extent of social impairment, a rating should not be assigned based solely on social impairment.  38 C.F.R. § 4.126(b).  The list of symptoms within the criteria is not exhaustive, so the impact of other symptoms particular to a veteran or a disorder on occupational and social functioning should also be considered.  Mauerhan v. Principi, 16 Vet. App. 436 (2002).  In this case, the Board has reviewed all of the evidence of record, but does not find that the Veteran’s psychiatric symptoms more closely approximate the criteria required for a higher 100 percent rating. The Veteran was afforded a VA general medical examination in July 2006, and he reported nightmares and night sweats every other week for the past six months. The Veteran attended a VA examination for PTSD in April 2008. The examination report reflects that the Veteran had been working for the same company for 26 years and worked rotating shifts. He stated that his symptoms of PTSD had not interfered dramatically with his work, but he reported some difficulty with his short-term memory and concentration. The Veteran was appropriately dressed and groomed, with clear and coherent speech, linear thoughts, and adequate judgment and insight. There was no sign of delusional content. The examiner found that he was experiencing only a mild level of impairment in social and occupational functioning. The Veteran was next afforded a VA mental disorders examination in March 2009. The examiner noted that the Veteran had some difficulty during the examination, and was unable to recall his age or date of birth. The Veteran stated that he stopped taking psychiatric medication because it made him “hallucinate more.” The Veteran reported that he had sleeping difficulties and was able to sleep only two-three hours a night, had nightmares three or four times a week, had difficulty with intrusive thoughts, experienced a depressed mood and feelings of hopelessness, and had flashbacks three to four times a week. The Veteran also reported problems with anger, irritability, exaggerated startle response, difficulty in crowds, and difficulty with loud noises. He stated that his wife was going to leave him due to his symptoms, and that the people he fought in Vietnam “keep trying to get [him].” The Veteran also reported that he had weapons in his home, which he used to defend himself from his hallucinations. The Veteran did not recall how long he has been married, related that he had no friends, and reported that he liked being outdoors, and “set booby traps in the woods” because people were trying to get him. He reported drinking daily, but denied the use of drugs or having any legal problems. He related that he had poor motivation to complete his activities of daily living, and only completed his basic hygiene once a week. The Veteran had difficulty with the mental status examination. He could not recall the year, the month, or the day of the week; he demonstrated difficulty with thought processes; he was a poor historian for personal information; his affect was blunted; his eye contact and insight were poor; his speech was slow but generally normal; he had trouble spelling short words; he had poor word recall; he was able to identify the current and past president; he reported hearing voices; he denied visual hallucinations; and he reported recent suicidal thoughts, but denied current suicidal or homicidal ideation or plans. The examiner diagnosed the Veteran with PTSD, and stated that the Veteran’s diagnoses of depressive disorder and alcohol abuse appeared related to his PTSD. The examiner stated that the Veteran’s memory difficulties and difficulty with cooperation on the mental health examination may be due to reluctance to cooperate with the examiner, or may potentially be related to cognitive impairment due to his alcohol abuse. The examiner stated that the Veteran’s overall level of impairment was moderate, with moderate to severe impairment in social functioning and mild impairment in occupational functioning. The examiner also noted that, based on the Veteran’s daily use to alcohol and his difficulty with the mental status examination, it appeared that the Veteran was not competent to manage his own funds in his own best interest. An addendum to the VA March 2009 examination report was issued in August 2010, once the examiner was able to review the Veteran’s claims file. The examiner noted that no changes were made to the examination. He wrote that the Veteran had moderate to severe impairment of social functioning and mild impairment in occupational functioning. He wrote that he was not competent to manage his funds due to the daily use of alcohol and his difficulty with the mental status examination. The Veteran underwent another VA examination in February 2012. The examiner noted that the Veteran experienced occupational and social impairment with reduced reliability and productivity. The examiner reported that the Veteran experienced depressed mood, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran reported that he did not participate in household finances, and that his spouse managed his financial affairs. The examiner related that there were no other changes since the last examination. The examiner wrote an addendum in March 2012. He explained that the Veteran’s symptoms waxed and waned in their severity, the symptoms were moderate to severe overall, and that he generally did not get involved in funds, but left this to his wife. The examiner was asked to write another addendum in April 2012, to explain whether his finding of incompetent equated to opining that his PTSD symptoms were so severe that they closely approximated a 100 percent evaluation. The examiner stated that the Veteran’s symptoms waxed and waned, from severe to higher functioning. The Veteran underwent another VA examination in September 2015. The examiner related that the Veteran experienced occupational and social impairment with reduced reliability and productivity. The Veteran told the examiner that his relationship with his spouse of many years was “great,” that he enjoyed travel and went to the beach six-seven times a year, that they traveled whenever possible, and that they often took bus tours with a group of 25 friends (some from church, some the Veteran’s). The Veteran also stated that he enjoyed restaurants. He related that he retired from manufacturing six years prior, always performed well on the job, and did not have any work-related issues. He stated that he had tried to keep busy since retirement, so as not to focus on intrusive thoughts. He reported that he was a trustee at his church, where he has belonged for over 30 years, and was very involved with projects there. He also related that he did projects around the house and garden, and was able to perform all his activities of daily living. The Veteran denied any suicidal or homicidal ideation or plan, and reported some improvement in his symptoms (especially a decrease in nightmares and intrusive thoughts). The Veteran denied any in-patient admissions, and stated that he no longer received outpatient treatment. The examiner stated that the Veteran experienced anxiety and suspiciousness. The examiner reported that the Veteran was now able to manage his own finances, as there has been some improvement in symptoms. He added that the Veteran’s overall functional impairment resulted in reduced reliability and productivity, and that the Veteran’s PTSD did not render him unable to obtain or maintain substantially gainful employment. The Veteran most recently attended a VA examination in November 2019. The Veteran reported that his marriage was rocky, but sometimes good. He reported occasional drinking, but that it did not have any negative impact on his functioning. The Veteran was found to have symptoms of depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty with relationships, inability to establish relationships, suicidal ideation. The Veteran was appropriately dressed, with withdrawn mood, restricted affect, normal speech, attention and concentration within normal limits, linear thought process, and no overt symptoms of psychosis. He denied any current suicidal ideation. He reported that his last suicidal ideation occurred when he came home from deployment. The examiner found that he had occupational and social impairment with reduced reliability and productivity. The Veteran’s Vet Center medical records show that he attended bi-monthly group therapy from July 2006 to November 2006 (four sessions total). The Veteran reported poor sleep (four to five hours), nightmares with night sweats (one to two times a month), some intrusive thoughts, being easily startled and hitting people, and hypervigilance. The Veteran had no thought disorder, he looked unkept, he was suspicious and defensive, he had above average intelligence, his speech was rapid and pressured, he was oriented to place and person, he had impaired memory, his affect was labile, he was tense, and his judgment was fair. The Veteran denied any homicidal or suicidal thoughts. The Veteran’s VA medical treatment records show that in November 2006, the Veteran denied any tobacco or alcohol use, stated that he performed all activities of daily living independently, and was employed as a laminator. The Veteran underwent a mental health evaluation in January 2007, which found that the Veteran had flashbacks, night sweats and nightmares, insomnia, depression, substance abuse, and the psychological stressors of marital discord and financial distress. The physician noted that the Veteran has worked as a laminator for 23 years and has been married for 34 years, had two grown children, was suspicious and distrustful of others, startled and got angry easily, and had anxiety and PTSD. The Veteran’s spouse stated that she was scared when the Veteran had nightmares. The Veteran appeared neat, had good eye contact, appropriate mood, and was oriented. Treatment notes from January 2007 to August 2010 showed ongoing individual psychotherapy with the above-listed symptoms, with an improvement in depression, less isolation, milder anxiety, improvement in hallucinations, occasional paranoid delusions, and avoidance of communication with his spouse. The Veteran told his counselor that his sleep difficulties stemmed from the fact that he worked rotating shifts, and often had to work at night. In addition, the Veteran consistently denied active suicidal or homicidal ideation. In 2009, he denied any delusions or hallucinations, and reported an improvement in his PTSD symptoms management. In May 2009, the Veteran reported suicidal thoughts, but no plan, and stated that he coped by doing things that relaxed and distracted him. In August 2010, the Veteran reported that he was not sure whether he should continue therapy, as the therapist whom the Veteran liked was no longer employed at VA. Further medical treatment notes show that the Veteran reported having good and bad days, variable mood, some sleeping problems, some nightmares, fair energy and good appetite, no crying spells, some feelings of hopelessness but no suicidal thoughts, irritability, no acting out or violence. The Veteran reported that going to church has helped him with his PTSD. He appeared casually dressed, with fair grooming and eye contact, was calm and cooperative, had normal psychomotor activity, was anxious, had restricted affect, appropriate mood, normal speech and thought processes, no hallucinations or delusions, was oriented, and had fair insight and judgment. The Veteran was noted to have loaded, unlocked weapons at home, but having a strong sense of responsibility to his family and being future-oriented. See March 2012 VA treatment note. The Veteran reported that he socialized little. See August 2013 VA treatment notes. In February 2014, the Veteran reported having variable mood, fair sleep, nightmares, fair energy, some feelings of hopelessness but no suicidal thoughts, and irritability. He did go to church, and his spirituality and faith had helped him to cope. In June 2014, he reported having good days and bad days, with some intrusive thoughts and distressing memories, avoidance, and bad dreams. His appetite was good, and he did some walking in the morning. He reported drinking wine a few times a month, but not on a regular basis. He had no suicidal thoughts, although at times he felt hopeless, but was able to work through this. He had no thoughts to harm others and no irritability. There were no psychotic symptoms reported, and he said his wife and brothers in law were supportive. He attended church and was a trustee. In both February and June 2014, the Veteran had fair grooming, had anxious mood, restricted affect, normal speech, logical thought process, fair judgment, was fully oriented, and had no suicidal ideation. Since 2014, the Veteran VA treatment records show that the Veteran has not received continuing mental health treatment, and has been regularly advised to follow up with his provider if his symptoms worsened. He has frequently denied any drug or alcohol use. The Board has also reviewed the lay statements submitted by the Veteran and his family members. In a June 2007 letter, the Veteran’s son wrote that he remembered his father having nightmares ever since he was a child, and that he was afraid that the Veteran would hurt one of the family members, as he would be ready to attack if he thought a stranger had broken into the house. The Veteran’s spouse has submitted several letters regarding her husband’s symptoms. In July 2007, she wrote that the Veteran has had a long history of nightmares and flashbacks. In a March 2009 letter, the Veteran’s spouse indicated that Veteran often acted detached and like he was “in a different world,” and did not have a relationship with his family. She related that he talked a lot about his time in Vietnam, and that she had to sleep in a separate room due to his sleep issues. She also reported that the Veteran’s hygiene was very poor, and she was the one who had to give him a bath, brush his teeth, and shave him. She testified in October 2011 that the Veteran had severe nightmares that scared their children, that he was reluctant to socialize, was hypervigilant, and that he had a temper. She stated that if she did not look after him, he would forget to order his medicine. She most recently submitted an Affidavit in October 2019, stating that her husband, prefers to be alone, has severe nightmares, is hypervigilant, can be in a daze, and is so distracted that he forgets to shower or brush his teeth. In his July 2009 statement, the Veteran reported that the most recent VA examination did not take into consideration that he did have both suicidal and homicidal ideation, as well as erratic behavior (as described by his spouse in her lay statement). At the October 2011 Board hearing, he reported that he had obsessional rituals, sleep impairment, and memory problems. He also reported having hallucinations that he described as intrusive thoughts that he was worthless. He also reported having feelings of hopelessness, being irritable, and shouting. He stated that his wife helped him with everything, and that he attended church occasionally, but did not belong to any outside groups. The Veteran wrote in an Affidavit received in October 2019 that he has flashbacks, anxiety attacks, nightmares, difficulty with memory, hypervigilance, and avoids interaction with people. He wrote that he typically stays at home, and that when he does du errands, such as getting groceries, he becomes extremely anxious in crowds. While the Veteran has demonstrated severe symptoms associated with his PTSD and depressive disorder, overall evidence is not reflective of total occupational and social impairment.  The evidence shows that the Veteran has suffered from depression, anxiety, sleep impairment, irritability, difficulty with relationships, isolation, hypervigilance, intrusive thoughts, possible hallucinations, neglect of hygiene, and memory impairment.  However, the evidence does not show that it has caused him total functional impairment.  The Board acknowledges that the Veteran’s symptoms have varied greatly in severity throughout the appeal period. At times, his symptoms have been no more than mild, while at least at one point his symptoms were severe, resulting in very poor memory and impaired cognitive abilities. The Board finds, however, that the 70 percent rating assigned takes this into consideration, and it fully compensates the Veteran for his period of more severe symptoms, and allows this rating to be in effect for the entire period on appeal, even though at times he was functioning very well. While the Veteran has at times been found to have a restricted affect and anxious mood, he has generally presented normally, with normal speech, adequate judgement and insight, and with logical thought processes. The Veteran has, for the vast majority of the appeal period, been found to have no psychosis, hallucinations, or delusions. The Veteran did report having hallucinations at the March 2009 VA examination, and his presentation was significantly worse than at all of his other VA examinations and VA appointments. His affect was blunted, his insight was poor, and he had difficulty with thought process. The Board accepts that this demonstrates some very severe symptomatology, but this evaluation is an outlier among all of the Veteran’s many other examinations and treatment appointments. The Veteran reported that he had been drinking daily, and the examiner found that the Veteran could have cognitive impairment due to alcohol abuse. The Board finds that even taking the Veteran’s March 2009 presentation into account, the Veteran was not been shown to have symptoms which were of the severity, frequency, and duration that would warrant a higher rating of 100 percent, which requires symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, or grossly inappropriate behavior. The Veteran has not been found to demonstrate any grossly inappropriate behavior. He has also never been found to have illogical, obscure, or irrelevant speech. The Veteran has indicated having hallucinations at times, although at the October 2011 Board hearing, he described these hallucinations as actually being intrusive thoughts. There is no indication that the Veteran ever had hallucinations or delusions which caused functional impairment, and since the March 2009 VA examination, he has repeatedly been found not to have any delusions or hallucinations. The Veteran has repeatedly been found to have insight and a solid understanding of reality.  He has never been found to be responding to internal stimuli or was unable to differentiate what was real from what was not.  The Board therefore finds that the evidence weighs against finding that these symptoms are of such severity, frequency, and duration that they constitute persistent delusions or hallucinations. The Veteran has also reported memory loss, and this significant symptom is consistent with a 70 percent rating. The criteria for a 100 percent rating do list symptoms such as disorientation to time or place and memory loss for names of close relatives, own occupation, or own name. The vast majority of the evidence indicates that the Veteran has always been able to recall these basic facts, such as his own name and occupation, and has in fact frequently discussed his work history and family life. The March 2009 VA examination is, again, an outlier, as this was the only time that he had difficulty answering basic questions, such as his age and date of birth. The Board does not find that this symptomatology has appeared with the frequency and duration that would warrant a higher 100 percent rating, and the Veteran’s disability picture overall shows that he has generally been able to recall basic facts about himself and his life. The Veteran and his spouse have both reported that he has trouble remembering to shower and brush his teeth, and that he needs to be reminded by his wife to take care of his hygiene. This is also a significant symptom, and neglect of appearance and hygiene is specifically listed in the rating criteria for a 70 percent rating. The Board finds that his symptomatology therefore adequately represents the type of symptom that constitutes the severity encompassed by a 70 percent rating. The Veteran has reported frequent problems with irritability and isolation, and these symptoms have affected his ability to hold employment or to socialize with other people. The Board acknowledges that these are serious symptoms, and they support the assignment of his 70 percent rating. He does, however, maintain generally good relationships within his family, including his wife, and has reported taking part in some activities, such as working in the yard, going to the beach, and going to church, where he is even a trustee. The Board therefore finds that his irritability and desire to isolate have not caused total social and occupational impairment. The Veteran reported having suicidal ideation after he first left the service as well in 2009, and in more recent years, he has expressed some feelings of worthlessness or hopelessness. These are also extremely serious symptoms. Suicidal ideation, without plan or intent, is, however, specifically included in the criteria for a 70 percent rating, and the Board does not find that this symptom indicates that a rating higher than 70 percent is warranted. The Veteran was never found, at any time during the appeal period, to have a suicidal plan or intent, to attempt to take his own life, or to be in danger of hurting himself or others. The Veteran has also reported that he gets support through his faith, which helps him to cope, and that while he has loaded weapons in his home, they were not found to be an immediate risk, because he reported having a strong sense of responsibility to his family and was future-oriented. The Board finds that taken into the context of the Veteran’s social functioning at this time, the severity, frequency, and duration of this symptom is not such that his overall psychiatric picture was comparable to the very severe and debilitating symptoms indicated for a 100 percent rating. The Board also notes that the evidence indicates that the Veteran has been found to have substantial interference with his ability to maintain employment due to his psychiatric symptoms.  This evidence is addressed below in the grant of a TDIU.  While the Veteran may be precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, the standards for this benefit are not the same as those required for a 100 percent rating under 38 C.F.R. § 4.130, and it is not sufficient to find that the Veteran has total occupational and social impairment.  The Board recognizes that the Veteran was temporarily deemed incompetent to handle his own finances during the appeal period. This finding, however, was based on the Veteran not being efficient at handling his money and financial obligations, and being forgetful. The Board does not find that this finding alone indicates that the Veteran’s PTSD symptoms were so severe that they closely approximated a 100 percent evaluation. While it does indicate that the Veteran had severe impairment in memory and his ability to responsibly handle money, looking at the evidence as a whole, the Board finds that a higher evaluation of 100 percent is not warranted. The Veteran is competent to report on his symptomatology as he observes them, and the Veteran’s reported symptoms throughout his treatment records and examinations are consistent with the already assigned 70 percent evaluation.  The Board has also considered the Veteran’s symptoms which are not included in the rating criteria listed under 38 C.F.R. § 4.130 and whether they constitute symptoms that would be comparable in type and degree (frequency, severity, and duration) to the criteria for a 100 percent rating.  See Mauerhan, 16 Vet. App. at 443.  The Veteran has been noted to have nightmares, hypervigilance, intrusive thoughts, and sleep impairment, which have occurred intermittently, with varying severity.  Although these symptoms are significant, the Board does not find that they are of a comparable severity to the very extreme symptomatology required for a rating of 100 percent.  In sum, the Board finds that a 100 percent rating is not warranted for any part of the appeal period.  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 a rating higher than 70 percent, that doctrine is not applicable.  38 U.S.C. § 5107(b).  TDIU The Veteran contends that he is unable to obtain or maintain gainful employment due to his impairment from PTSD. The Veteran wrote in October 2019 that he had not worked since early 2009, when he was laid off from his job as a laminator. He wrote that his PTSD had profoundly impacted his ability to work even then, such as memory problems and intrusive thoughts. The Veteran wrote that his inability to adapt to change was part of the reason he was laid off. VA will grant a total disability evaluation based on individual unemployability due to service-connected disorders when the evidence shows that a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities.  38 C.F.R. §§ 3.340, 3.341, 4.16. Regarding the appropriate effective date for the assignment of a TDIU, the current claim for a TDIU arose from a claim for an increased initial rating for PTSD, which was submitted on March 2, 2006. On his June 2019 Application for Increased Compensation Based on Unemployability, the Veteran wrote that he last worked in 2009, but did not provide an exact date. Prior to this, he wrote that he was working as a laminator 40 hours a week, and he reported income that was well above the poverty level limit. At the March 24, 2009 VA examination, the Veteran told the examiner that he stopped working approximately three months ago because his position was terminated. The Veteran related that he worked in his position as a laminator for 20 years, worked alone, was always on time for work, and performed adequately at his job. The Veteran’s VA treatment records show that on February 4, 2009, he reported that he was still working as a laminator, doing rotating 12 hour shifts. Because this evidence indicates that the Veteran was still working at the start of February 2009, but was no longer working by the March 2009 VA examination, this examination date is the earliest factually ascertainable date that it is shown that the Veteran was unemployed, and the Board finds that March 24, 2009, is the earliest date that a TDIU can be awarded. The period currently under consideration for the claim of entitlement to a TDIU is therefore from March 24, 2009, to the present. This is consistent with the Veteran’s reports that he stopped working in early 2009 and the vocational assessment submitted by the Veteran that indicates that he stopped being able to work in April 2009. The Veteran is service connected for PTSD, rated as 70 percent disabling; prostate cancer, rated as 100 percent disabling from May 4, 2018 and 10 percent disabling from August 1, 2020; and erectile dysfunction, rated as 0 percent disabling. His total evaluations have been 70 percent from March 2, 2006; 100 percent from May 4, 2018, and 70 percent from August 1, 2020. He therefore has met the criteria to be eligible for a schedular TDIU under 38 C.F.R. § 4.16(a).  Although the Veteran was assigned a 100 percent total evaluation from May 4, 2018 to July 31, 2020, the Court held in Bradley v. Peake, 22 Vet. App. 280 (2008) that there could be situations where a veteran has a total rating for a particular disability, and could establish entitlement to a TDIU for another service-connected disability to qualify for special monthly compensation under 38 U.S.C. § 1114(s). In this case, the Veteran had both a 100 percent rating for prostate cancer and a 70 percent rating for PTSD, which is the basis for his unemployability. The Board therefore finds that the issue of entitlement to a TDIU remains on appeal for the entire period on appeal. Resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to a TDIU is warranted. The Veteran has submitted probative medical evidence which indicates that his service-connected PTSD prevents him from being able to obtain or maintain gainful employment. The Veteran submitted a September 2019 private vocational assessment. The examining rehabilitation counselor conducted a telephone interview with the Veteran and reviewed his medical history. She wrote that the Veteran had worked as laminator from 1980 until approximately April 2009, when he was laid off. She wrote that although the Veteran had acquired multiple skills through his vocational history, he would not be able to execute these skills due to his inability to maintain concentration, persistence and pace, in addition to his inability to recall multi-step tasks. She wrote that the Veteran had difficulties with concentration, as well as anxiety, intrusive thoughts, decreased motivation, memory impairment, and sleep impairment, which would cause him to be unable to meet the pace and productivity demands of competitive employment. He was also unable to interact appropriately and effectively with others, which is a requirement of all employment, regardless of skill level. She concluded that it was at least as likely as not that the Veteran had been unable to secure and follow substantially gainful employment, including unskilled sedentary employment, since at least April 2009 to the present, due to his PTSD. The Board accepts that this medical opinion is based on an accurate understanding of the Veteran’s medical history and contentions, it is consistent with the other medical evidence of record, and the rehabilitation counselor provided adequate discussion and rationale for her findings. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation). It is therefore afforded great probative weight in deciding the claim. While the other evidence of record has shown varying levels of impairment due to PTSD, the Board accepts that the Veteran’s symptoms of PTSD have been severe, and the September 2019 vocational assessment does accurate represent the Veteran’s functioning overall and the likely impact his symptoms would have on work. The private evaluation’s findings are consistent with those of the November 2019 VA examination, which found that the Veteran did have significant deficits in his ability to manage distress, navigate conflict with others, and to tolerate interpersonal interactions with others. Other records also show that the Veteran, at times, has severe problems with memory, which the Board acknowledges would cause great difficulty in maintaining any type of job. The Board therefore finds that adequate medical evidence indicating that the Veteran’s service-connected PTSD has prevented him from being able to maintain any gainful employment since March 24, 2009. Entitlement to a TDIU is granted. Special Monthly Compensation Based on a Need for Aid and Attendance The Veteran’s attorney has asserted that the Veteran should also be entitled to special monthly compensation based on a need for aid and attendance, and in January 2020, the Board added this issue to the current appeal. The attorney has argued that the Veteran requires the aid and attendance of his wife because he is not able to manage his own funds and requires assistance from his wife with hygiene and bathing. The Veteran submitted an Affidavit in October 2019, and he wrote that he was dependent on his wife because he could not keep track of money, would overspend it, or would lose it. He wrote that he often forgets to shower or maintain his hygiene, so his wife reminds him to shower. He wrote that he has trouble remembering the date and time or appointments, so his wife keeps track of them. In a March 2009 letter, the Veteran’s spouse indicated that Veteran often acted detached and like he was “in a different world.” She also reported that the Veteran’s hygiene was very poor, and she was the one who had to give him a bath, brush his teeth, and shave him. She most recently submitted an Affidavit in October 2019, stating that her husband prefers to be alone, has severe nightmares, is hypervigilant, can be in a daze, and is so distracted that he forgets to shower or brush his teeth. She wrote that he frequently has to remind him to do these tasks, and that he is completely reliant on her to cook and clean. She wrote that she also handles all of his financial affairs, and that she is constantly concerned that he will be duped or taken advantage of. Special monthly compensation is payable under several circumstances, including when a veteran is permanently bedridden or so helpless as to be in need of the regular aid and attendance of another person. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. A veteran shall be considered to be in need of regular aid and attendance if: he 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 5 degrees or less; or 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. Determinations as to the need for aid and attendance are based on the actual requirements of personal assistance from others. In determining the need for regular aid and attendance, consideration will be given to the inability of the Veteran to dress or undress himself, or to keep himself clean; frequent need of adjustment of any prosthetic which by reason of the disability cannot be done without aid; inability of the Veteran to feed himself; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect himself from the hazards or dangers of his daily environment. Bedridden will be that condition which, through its essential character, actually requires that the Veteran remain in bed. 38 C.F.R. § 3.352. It is mandatory for VA to consider the enumerated factors within the regulation; at least one of the enumerated factors must be present. Turco v. Brown, 9 Vet. App. 222 (1996). The Board has reviewed all of the evidence of record, but finds that the preponderance of the evidence does not demonstrate that the Veteran is in need of aid and attendance from another person. The Veteran is not permanently bedridden, and he has not asserted that he is. He is also not blind or nearly blind, and he is not a patient in a nursing home. None of the VA examinations of record of the VA treatment records indicate that the Veteran is unable to dress himself, bath himself, prepare food, feed himself, or protect himself from the hazards or dangers of his daily life. The April 2008 VA examiner found that the Veteran was capable of completing household chores and activities of daily living without assistance. The Veteran’s most severe presentation was at the March 2009 VA examination, at which he reported that he had poor motivation to complete his activities of daily living, and only completed his basic hygiene once a week. The examiner also found that the Veteran was not competent to manage his own funds in his own best interest, due to his memory problems and daily drinking. While it is significant that the Veteran was, at this time, found to be not responsible with funds, as the Board discussed above, this examination is an outlier, and the Veteran’s cognitive impairment appears to be largely due to the Veteran’s heavy drinking at this time. The Veteran was not found to be incapable of performing activities of daily living, but only that he had low motivation for hygiene. The Board does not find that this indicates that the Veteran was incapable of performing his activities of daily living, but only that his motivation was low, and he benefited from reminders. The Board also finds that this temporary period of inability to handle finances is not sufficient to establish a need for aid and attendance, and notes that the Veteran was subsequently found to be competent to manage his own finances. At the September 2015 VA examination, the Veteran reported that he frequently went to the beach, traveled when possible, was a trustee at his church, and had been doing projects around the house and in the garden. He was found to be able to perform all activities of daily living. The Veteran attended a VA examination in December 2020. The Veteran was well dressed for the season and ambulated well. No abnormal pathology or anything to limit travel or ability to self-care was found. The Veteran reported that he did not have a medical condition that required aid and attendance. He reported that he was mobile and had multiple joint pain, but was independent enough to complete activities of daily living. The examiner found no findings, signs, or symptoms to support a diagnosis indicating aid and attendance was necessary. The examiner found that the Veteran was able to feed himself and prepare his own meals, and he did not need assistance in bathing and tending to other hygiene needs. The Veteran did not require medication management and did have the mental capacity to manage his benefit payments. This evidence, overall, demonstrates that the Veteran has had periods of severely low motivation and alcohol abuse, during which he neglected his personal hygiene and needed to be reminded to bathe by his wife. While she wrote in 2009 that she had to give him a bath, brush his teeth, and shave him, her subsequent statements, the statements of the Veteran, and their testimony indicate that this was really meant to indicate that she has to prompt the Veteran to do these things because he would forget or not feel inclined to do them otherwise, not that she was physically bathing the Veteran or brushing his teeth for him. But even during the Veteran’s more severe periods of psychiatric impairment, he has never been found to be incapable of bathing, dressing, or feeding himself. Furthermore, since the March 2009 VA examination, the Veteran has shown significant improvement in motivation, and his more recent VA treatment records show that he has decreased his drinking and has always presented normally and appropriately groomed. The Veteran is competent to report whether or not he completes his own activities of daily living. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds no reason to believe that the Veteran was not being truthful when speaking to the December 2020 VA examiner or that he was not competent at that time to report on his own ability to bathe, dress, and fix meals. The Veteran himself reported that he does not have a medical condition that required aid and attendance and that he was independent enough to complete activities of daily living. The December 2020 VA examiner found that the Veteran prevented with no pathology which would prevent him from being able to bathe, dress, or feed himself. The Board acknowledges that VA regulations include that a veteran could qualify for aid and attendance if he requires care or assistance to protect himself from the hazards or dangers of his daily environment due to mental incapacity, as well as due to physical incapacity. 38 C.F.R. § 3.352(a). While it is clear that the Veteran’s wife does provide significant support for the Veteran, including managing their finances, cooking his meals, and reminding him to bathe and shave, the Veteran has generally been found to be capable of performing these activities as long as he is reminded to do them. He has reported that he does help around the house and work in the garden, and he is even a trustee in his church. The Board does not find that his problems with memory and motivation are of such severity that they render him unable to protect himself from the hazards or dangers of his daily environment. The Board notes that the Veteran is also service connected for prostate cancer and erectile dysfunction. He has not asserted, however, that these disabilities have had any impact on his ability to perform activities of daily living, nor is there any evidence that they have caused him to require the aid and attendance of another person. In arriving at this decision, the Board recognizes that the Veteran has significant impairment due to his PTSD, including difficulty dealing with people and memory problems. This severity is reflected by the 70 percent rating assigned for the disability and the award of a TDIU. The preponderance of the evidence demonstrates, however, that the Veteran is capable of performing activities of daily living and protecting himself from the hazards of his daily environment, and he is not in need of regular aid and attendance in performing activities of daily living. Accordingly, he does not meet or more nearly approximate the criteria for special monthly compensation on those bases. Entitlement to special monthly compensation based on a need for aid and attendance is denied. The Board has again considered the doctrine of reasonable doubt, but the preponderance of the evidence is against the claim. 38 U.S.C. § 5107(b). DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mary E. Rude, 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.