Citation Nr: 21015656 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 13-10 695 DATE: March 18, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities, is denied. Entitlement to an initial rating of 70 percent, but no higher, for major depressive disorder is granted. Entitlement to a disability rating in excess of 70 percent for major depressive disorder is denied, including the period from October 10, 2019. Entitlement to a total disability rating based on individual unemployability for the period prior to March 11, 2015 and for the period from October 10, 2019 is granted. Entitlement to special monthly compensation by reason of being housebound or based on the need of regular aid and attendance is denied. FINDINGS OF FACT 1. The Veteran’s hypertension is not related to his service or any incident therein, and is not related to, secondary to, due to or aggravated by any service-connected disability. 2. Throughout the appeal period, the Veteran’s service-connected major depressive disorder (MDD) has resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 3. Throughout the appeal period, the Veteran’s service-connected MDD has not resulted in total occupational and social impairment. 4. For the period prior to March 11, 2015 and for the period from October 10, 2019, the Veteran’s MDD prevented him from obtaining and maintaining employment consistent with his occupational and vocational experience. 5. The Veteran’s service-connected disabilities do not render him so helpless as to be in need of regular aid and attendance of another person, nor do they render him housebound. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, to include as secondary to service-connected disabilities, are not met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 2. The criteria for an initial rating of 70 percent, but no higher, for service-connected MDD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9434. 3. The criteria for a disability rating in excess of 70 percent for service-connected MDD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9434. 4. For the period prior to March 11, 2015 and for the period from October 10, 2019, the criteria for a total disability rating based on individual unemployability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.15, 4.16. 5. The criteria for entitlement to special monthly compensation based on the need of regular aid and attendance or being housebound are not met. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.351, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 2005 to June 2008. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a July 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in which the RO, as pertinent to this appeal, granted service connection for MDD with an evaluation of 10 percent effective June 23, 2008 and denied service connection for high blood pressure. Under Rice v. Shinseki, the Board has jurisdiction over a total disability rating based on individual unemployability (TDIU) claim as part and parcel of the Veteran’s increased rating claim if raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a request for TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate “claim” for benefits, but rather, is part of a claim for increased compensation). Under Akles v. Derwinski, the Board has jurisdiction over a claim for special monthly compensation (SMC) as inferred based on the record. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991) (finding that a claim for an increased rating can include entitlement to SMC as an inferred issue); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (stating that SMC benefits are to be accorded when a veteran becomes eligible without need for a separate claim). Accordingly, this issue has been separately characterized in the issues above. As pertinent to this appeal, the matters were previously before the Board in November 2016 and again in February 2019, at which time the claims were remanded for further development. The case has now returned to the Board for appellate review. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities The Veteran contends that his hypertension is due to active duty service or is secondary to his service-connected disabilities. Establishing service connection on a direct basis requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disease or injury. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996). Establishing service connection on a secondary basis requires evidence (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Additionally, where a veteran served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) and certain chronic diseases, including hypertension, become manifest to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). Hypertension is on the list of chronic diseases which may be established by showing continuity of symptomatology after service. 38 C.F.R. § 3.309(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this case, a diagnosis of hypertension is of record and the first element of service connection is thus met. See October 2019 VA Hypertension Examination Report. As to the second element for direct service connection, in-service incurrence or aggravation of a disease or injury, a review of the Veteran’s service treatment records (STRs) reveals elevated blood pressure readings on two occasions, including his November 2005 entrance examination. The entrance examiner made no comment on the elevated blood pressure. The second occurrence was in October 2007 when the Veteran presented complaining of nausea, vomiting, sweats and myalgia. A blood pressure check was repeated during the evaluation and the Veteran was noted to be anxious over upcoming combat training. Otherwise, his STRs show blood pressure readings within normal limits, routine denials of high or low blood pressure as well as examiner findings of normal blood pressure. Neither high blood pressure nor hypertension are noted in any problems list during service, nor is either disorder mentioned by any in-service examiner to be of concern or noted for follow up or a 5-day blood pressure check. The Board notes the Veteran’s STRs show that he received medical treatment for a variety of reasons during his active duty service, including being hit in the head by a steel bar which resulted in a lower jaw fracture and necessitated surgery for repair, being hit with an elbow to the face, several falls and common complaints of flu and/or cold symptoms. Some of these events required specialized medical care, but there is nothing showing any noted concern for high blood pressure or hypertension in his STRs, even during these specialized medical care events. Based on this evidence, the Board finds that the second element of a service connection claims is not satisfied. Hypertension is a disability subject to presumptive service connection if it is manifest to a compensable degree within a year of active service. 38 C.F.R. §§ 3.307, 3.309(a). The Veteran’s post-service VA treatment records show an elevated blood pressure reading of 134/95 in December 2008 when he presented in the emergency department with complaints of anxiety, and that in June 2010, two years after separation, he reported elevated blood pressure up to 180/100 and that his physician recommended a home blood pressure machine for daily morning blood pressure checks. His VA treatment records, however, show blood pressure readings within normal limits and do not support the Veteran’s self-reported readings. See, e.g., June 2010, January 2010 and May 2009 VA Treatment Records. A July 2010 VA treatment note shows an elevated systolic reading with normal readings during follow up a week later. The Board notes the elevated readings were not enough to cause the healthcare providers to order multiday blood pressure checks or to start the Veteran on medication. VA treatment records show that the Veteran was prescribed Metoprolol for elevated blood pressure in February 2014 and a May 2015 diagnosis of hypertension, approximately seven years after separation. This diagnosis is too remote in time to qualify for presumptive service connection under 38 C.F.R. § 3.307. There is also no evidence of symptoms being continuous from the time of separation to his eventual diagnosis; service connection on a continuity of symptomatology basis is thus similarly precluded. The Veteran, however, contends that his hypertension is secondary to his service-connected disabilities. In this regard, the Board acknowledges that the Veteran’s representative cited medical articles regarding a correlation between hypertension and psychological status. See January 2019 Appellate Brief. However, the Board finds that this evidence does not provide probative evidence of a nexus in this Veteran’s case. Rather, generic information from a medical journal, treaties or website are too “general and inconclusive” to establish a medical nexus to a disease or injury, and without application to the specific facts of the Veteran’s case does little to support his claim. See Sacks v. West, 11 Vet. App. 314, 316 17 (1998) (holding that a medical article or treatise can provide support for a claim, but must be combined with an opinion of a medical professional and be reflective of the specific facts of a case as opposed to a discussion of generic relationships); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (finding that generic medical literature, which does not apply medical principles to the facts of an individual case, does not provide competent evidence). The Veteran underwent a VA hypertension examination in October 2019, at which time the VA examiner opined that his hypertension was less likely than not proximately due to or a result of his service-connected disabilities. The examiner noted that in-service healthcare providers did not find evidence of a head injury causing medulla injury, which may have affected blood pressure. The examiner further noted that a 2018 VA neurology examination did not find significant head injury sequelae. The examiner opined that the Veteran’s hypertension was less likely aggravated by his service-connected disabilities because none of the disabilities is known to be an independent factor in long-term hypertension and is therefore at least as likely idiopathic and not caused by in-service injury. The examiner noted that headaches may raise blood pressure during a headache, but should not cause long-term elevations. The Board finds the October 2019 medical opinion adequately supported and highly probative. While the Veteran has attempted to establish a nexus, he is not competent to offer opinions as to the etiology of his current hypertension disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Hypertension requires specialized training for determinations as to diagnosis and causation, and is therefore not susceptible to lay opinions on etiology. Thus, the Veteran is not competent to render such a nexus opinion or attempt to present lay assertions to establish a nexus between his current diagnosis and its relationship to his service. Additionally, the Board notes that while the Veteran’s VA treatment records prior to his diagnosis show occasional mildly elevated readings, consistent blood pressure readings within normal limits are otherwise shown. Hypertension was diagnosed in May 2015, approximately seven years after the Veteran’s separation from service, and more than eight years after the onset of MDD symptomatology. The length of time between separation and the onset of MDD symptomatology, and the diagnosis of hypertension is another factor that weighs against the Veteran’s claim. Because the competent and probative evidence of record does not support in-service incurrence or aggravation of a disease or injury, and further fails to indicate a connection between the Veteran’s current hypertension and his service-connected disabilities, service connection for hypertension on a direct or secondary basis is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. 2. Entitlement to an initial rating of 70 percent, but no higher, for MDD 3. Entitlement to a disability rating in excess of 70 percent from October 10, 2019 for MDD The Veteran contends that his service-connected MDD symptomatology warrants a higher disability rating than the initial 50 percent rating and the currently assigned 70 percent rating from October 10, 2019. Disability evaluations are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. § Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found; this practice is known as staged ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. The Veteran’s MDD has been evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9434. A 50 percent rating is warranted for 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9434. A 70 percent rating is warranted when there is 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is 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. The symptoms listed in DC 9434 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002); see also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (explaining that the symptoms that could give rise to a given rating are those in like kind, i.e., of similar duration, severity, and frequency, to those provided in the non-exhaustive lists). The rating of psychiatric disorders is ultimately based upon their resultant level of occupational and social impairment. 38 C.F.R. § 4.130; Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (2013). The evaluation, however, is symptom-driven, meaning that the symptomatology should be the fact-finder’s primary focus in determining the level of occupational and social impairment. Id. at 116-17. This includes consideration of the frequency, severity, and duration of those symptoms. 38 C.F.R. § 4.126(a); Vazquez-Claudio, 713 F.3d at 117. Significantly, however, the symptoms enumerated in the rating criteria are merely examples of those that would produce such level of impairment; they are not exhaustive, and VA is not required to find the presence of all, most, or even some of the enumerated symptoms to assign a particular evaluation. Id. at 115; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the Board finds that the Veteran demonstrates symptoms of similar severity, frequency, and duration that cause occupational and social impairment equivalent to that which would be produced by the specific symptoms enumerated in the rating criteria, then the appropriate equivalent rating will be assigned. 38 C.F.R. § 4.21; Mauerhan, 16 Vet. App. at 443; see also Vazquez-Claudio, 713 F.3d at 117. Separate ratings can be assigned for separate periods based on the facts found – a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. By way of background relevant to this appeal, the RO granted entitlement to service connection for MDD in a July 2009 rating decision and assigned a disability evaluation of 10 percent effective June 23, 2008, the day after the date of the Veteran’s discharge. The Veteran timely disagreed and in a March 2013 rating decision, the RO increased the initial disability rating to 30 percent and to 50 percent rating effective August 21, 2012, the date a VA examination showed that his MDD increased in severity. The Veteran timely appealed the claim and the Board remanded the claim for further development in November 2016. In a November 2018 rating decision, the initial rating was increased to 50 percent and continued for the period from August 21, 2012. The claim returned in front of the Board and was again remanded in February 2019. In a June 2020 rating decision, the RO continued the initial 50 percent rating and increased the rating to 70 percent effective October 10, 2019, the date a VA contract examination confirmed the MDD diagnosis and showed that the Veteran’s reported symptoms most reflect a 70 percent disability rating. After reviewing the pertinent evidence of record, the Board finds that the Veteran’s MDD symptoms are of such severity, frequency and duration as to warrant an initial 70 percent disability rating. VA treatment records and mental disorders examinations throughout the course of the appeal show that the Veteran consistently presented with depression and anxiety which he reported as constant, and show a history of suicide attempts, suicidal ideation and self-cutting behavior. See, e.g., March 2014, March 2012 and December 2008 VA Treatment Notes and October 2019, August 2012 and February 2009 VA Mental Disorders Examination Reports. The Veteran reported active suicidal ideation in December 2008, August 2012 and April 2014. In May 2014, the Veteran called suicide prevention, reporting daily suicidal thoughts. In January 2009, the Veteran reported an in-service suicide attempt in December 2007. See January 2009 VA Mental Disorder Examination Report. The Veteran also reported increased difficulty maintaining effective relationships over the course of the appeal. For example, in connection with the February 2009 VA examination, the Veteran reported he lost friends due to increased irritability and that he found it more difficulty to get along with others. Also, the record shows that the Veteran reported getting in physical fights, including with a co-worker friend, his biological father and his brother. See April 2014 VA Treatment Note, August 2012 VA Mental Disorder Examination Report, June 2008 Mental Health Clinic Note and December 2007 STR. Additionally, in connection with the August 2012 VA examination, he reported his enrollment in computer classes but also reported irritability and a lack of patience leading to arguments with other students and teachers. In May 2014, the Veteran reported that his only social support was his girlfriend, that he hated his brother and that he burned bridges with his drinking friends. In March 2016, the Veteran reported that he dropped out of college because of depression and in October 2019, the VA contract examiner noted that the Veteran’s MDD is progressively worse and now meets the DSM-5 criteria of MDD severe with alcohol in remission, a progression of the established MDD diagnosis. The February 2009 VA examiner noted that the Veteran’s affect and mood showed a depressed mood which occurred near-continuously and affected his ability to function independently. The October 2019 examiner made substantially the same finding. The Veteran’s post-service medical treatment records similarly show notes of severe depression and near-constant irritability and anger. See, e.g., September 2016, May 2014, April 2012 and November 2010 VA Treatment Notes. The August 2012 examination report shows that the Veteran reported a self-cutting history, noting he does not cut himself anymore. He further reported that after he stopped the cutting behavior, he would break things when he got frustrated, such as punching holes in walls and breaking windshields with his fists. His VA treatment records show that in December 2013, the Veteran presented to the emergency department after his involvement in a brawl with a friend. The record also shows that he attended several sessions of a VA Anger Management Group in April 2014 and that in September 2016, a VA social worker reported the Veteran identified his irritability and becoming easily annoyed, among other symptoms, as frequently present and disruptive of activities, and further that he needed help addressing these symptoms. The October 2019 VA contract examiner found the Veteran’s MDD causes occupational and social impairment with reduced reliability and productivity based on his symptoms of depressed mood, anxiety, near-continuous panic or depression affecting his ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work-like setting and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner noted the Veteran’s diagnosis of traumatic brain injury (TBI), but opined that his MDD is more severe and causes a moderate degree of functional impairment in occupational and social settings during times of significantly higher stress in occupational settings, while his TBI symptoms are mild with no functional impairment. The Board notes that while his VA treatment records show the Veteran was consistently alert and oriented with normal speech and thought content throughout the period on appeal, the evidence shows a pattern of suicidal ideation, near-continuous depression or panic affecting the ability to function independently, appropriately and effectively, impaired impulse control, such as unprovoked irritability with periods of violence, difficulty in establishing and maintaining effective work and social relationships and difficulty adapting to stressful circumstances, including work or a work like setting of such severity, frequency and duration that the Veteran’s disability picture and symptoms more nearly approximate the approximate the 70 percent rating criteria. A higher, 100 percent rating is not warranted for any period of time during the appeal period as the evidence of record does not support a finding that the Veteran exhibits the level of cognitive, occupational and social impairment that render him totally occupationally and socially impaired as a result of the type of symptoms listed in the general rating schedule or symptoms of a similar degree. There have been no deficiencies of the severity contemplated by a 100 percent rating identified in the Veteran’s thought processes or communication, nor has there been any indication of disorientation or grossly inappropriate behavior. Similarly, while the record shows some objective evidence of mild memory loss, the Veteran has never reported memory loss of the severity contemplated by a 100 percent rating. Also, while a July 2014 VA treatment record notes a lengthy history of hallucinations, the medical evidence of record does not support this finding. The Veteran reported possible hypnogogic hallucinations in January 2009 and in seeing demons and being held by an angel April and May 2014, but otherwise routinely denied auditory or visual hallucinations. In May 2014, a VA staff psychologist opined that the Veteran’s reported hallucinations did not indicate a psychosis, but rather indicated more of a belief in the supernatural with a desire for examining this perspective. As such, the preponderance of the evidence shows that the Veteran’s psychiatric symptomatology does not more closely approximate the criteria for a 100 percent disability rating under the general rating schedule for psychiatric disorders at any time during the appeal period. The Board therefore finds that the Veteran’s service-connected MDD symptomatology warrants an initial disability rating of 70 percent, but no higher, effective June 23, 2008, and further finds that no more than a 70 percent rating is appropriate for the entire period on appeal, including the period from October 10, 2019. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 4. Entitlement to a TDIU for the period prior to March 11, 2015 and for the period from October 10, 2019 It is the established policy of the VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. A total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Entitlement to a TDIU is based on an individual’s particular circumstances. 38 C.F.R. § 4.16; Ray v. Wilkie, 31 Vet. App. 58, 72 (2019) (quoting Rice v. Shinseki, 22 Vet. App. 447, 452 (2009); Todd v. McDonald, 27 Vet. App. 79, 85-86 (2014). Thus, in adjudicating a TDIU claim, VA must consider the individual veteran’s education, training, and work history, but not his or her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Todd, 27 Vet. App. at 85-86. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected disabilities, provided that one of those disabilities is ratable at 40 percent or more, and there is sufficient additional service-connected disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Nevertheless, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). The phrase “unable to secure and follow a substantially gainful occupation” in § 4.16 has both an economic and a noneconomic component. Ray, 31 Vet. App. at 73. The economic component means an occupation earning more than marginal income outside of a protected environment. Id. The noneconomic component concerns whether the Veteran is able to “secure or follow” gainful employment. Id. In determining whether a Veteran can secure and follow a substantially gainful occupation, the Board should consider the Veteran’s history, education, skill, and training; whether he or she “has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required” to work in a substantially gainful occupation, and “whether the Veteran has the mental ability to perform the activities required” to work in a substantially gainful occupation. Id. In light of the Board’s findings herein, the Veteran is service-connected for: MDD, evaluated as 70 percent disabling from June 23, 2008; migraine headaches, evaluated as 50 percent disabling from April 11, 2013; TBI, evaluated as 10 percent disabling from December 17, 2009 and as 40 percent disabling from April 11, 2013; status post jaw fracture with temporomandibular joint dysfunction and headaches (TMJ), evaluated as 10 percent disabling from June 23, 2008, as 20 percent disabling from December 17, 2009 and as 40 percent disabling from March 11, 2015; low back strain, evaluated as 10 percent disabling from June 23, 2008 and as 20 percent from August 29, 2012; tinnitus, evaluated as 10 percent disabling from April 11, 2013; left malar complex fracture, with a noncompensable rating from July 1, 2009; and gastritis, with a noncompensable rating from June 23, 2008. Thus, the Veteran’s combined evaluation was 80 percent from June 23, 2008, 90 percent from December 17, 2009 and 100 percent from April 11, 2013. The Veteran contends that his service-connected disabilities prevent him from working in a substantially gainful occupation. See March 2015 VA Form 21-8940. A review of the record shows that the Veteran has not secured and followed a substantially gainful occupation since his separation from service. See March 2015 VA Form 21-8940 and February 2009 VA Mental Disorders Examination Report. With the Board’s finding herein that his MDD symptomatology causes occupational and social impairment in most areas and the grant of an initial 70 percent disability rating for MDD, the Veteran met the schedular requirements for TDIU effective June 23, 2008. In the June 2020 rating decision, the RO granted a TDIU for the period from March 11, 2015 to October 10, 2019 and found that as of October 10, 2019, TDIU became moot because the Veteran met the schedular criteria for a combined 100 percent evaluation. See June 2020 Rating Decision. However, under Rice the issue of TDIU is part and parcel of the Veteran’s claim for an increased rating for MDD and as such, the issue of entitlement to TDIU is not moot for the period prior to March 11, 2015 and remains before the Board. The Veteran’s total schedular rating beginning April 11, 2013 might appear to preclude the assignment of a total rating on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding a request for TDIU moot where a 100 percent schedular rating had been awarded for the same period). However, where a single disability is rated as 100 percent disabling, or where a single disability forms the basis for a TDIU, consideration of a TDIU is warranted even in the presence of a 100 percent schedular rating because it may give rise to entitlement to SMC. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008); see also 38 U.S.C. § 1114(s) (providing for the assignment of SMC where “the veteran has a service-connected disability rated as total [and] has additional service-connected disability or disabilities independently ratable at 60 percent or more”). The central inquiry in a claim for TDIU is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to a veteran’s education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). After a review of the evidence, for reasons set forth below and resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran’s service-connected MDD, alone, precludes him from engaging in substantially gainful employment prior to March 11, 2015 and for the period from October 10, 2019. The record shows that the Veteran reported the he graduated high school on the honor roll prior to service and that after service, he began taking computer courses but stopped due to depression. See March 2016 VA Treatment Note. In October 2019, the Veteran reported his return to school but is currently taking a break and is not currently employed. See October 2019 Mental Disorders Examination Report. There is no indication that the Veteran has obtained his college degree or that he has obtained employment. His reported pre-service occupational experience is as a cashier and in customer service and sales for six months at a pharmacy, for 10 months at an auto parts store and for two months at a toy store and that all these jobs were temporary and/or part-time positions. The Veteran’s last reported employment of record was seasonal work from October 2009 to December 2009. The evidence of record reveals that the Veteran has difficulty getting along with fellow students and teachers, has lost friends and dropped out of college as a result of his MDD symptomatology of suicidal ideation, difficulty establishing and maintaining effective work / school and social relationships due to irritability and anger, difficulty concentrating, reduced socialization and severe depression. See, e.g., August 2012 Mental Disorder VA Examination Report, February 2011 VA Treatment Note and February 2009 Mental Disorder VA Examination Report. In a March 2011 vocational rehabilitation feasibility worksheet, Veteran’s case manager found that he has a serious employment handicap based on the number and severity of disabling disorders, an unstable work history, long or substantial periods of unemployment, a record of or current neuropsychiatric disorders, chronic pain, a lack of education / training for suitable employment and difficulties with communicating. His case manager noted that the Veteran had difficulty with the physical demands and the social aspects of his last job, has limited education and has an employment history marked by short-term jobs and long-term unemployment. The Board notes that in the June 2020 rating decision, the RO found a TDIU became moot as of October 10, 2019 because the Veteran met the schedular criteria for a combined 100 percent evaluation as of that date. However, the award of a 100 percent schedular rating (combined or individual) does not necessarily moot the award of a TDIU, and the award of TDIU does not moot a claim for an increased rating. See Bradley v. Peake, 22 Vet. App. 280 (2008). VA regulations allow for benefits in addition to a 100 percent rating in certain circumstances. Most frequently, SMC is available for an appellant with a single service-connected disability rated at 100 percent and additional, separate, disabilities independently ratable at 60 percent or more. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350 (i). Thus, in this Veteran’s case, the Board finds that entitlement to a TDIU is not moot for the period from October 10, 2019, as a TDIU based on a single service-connected disability can serve as a single disability rated as total for purposes of an award of SMC at the housebound rate. As discussed above, the October 2019 examiner found that the Veteran’s MDD causes a moderate degree of functional impairment in occupational and social settings during times of significantly higher stress in occupational settings. Based on his report of current symptoms during the October 2019 examination and his reports of consistent MDD symptomatology over the course of the entire period of appeal of suicide attempts, suicidal ideation, self-cutting behavior, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, difficulty adapting to stressful circumstances, including work or a work like setting, the inability to establish and maintain effective relationships, and impaired impulse control, such as unprovoked irritability with periods of violence, the Board finds that the Veteran is unable to secure or maintain gainful employment due to his service-connected MDD alone. Therefore, TDIU is granted for the period prior to March 11, 2015 and for the period from October 10, 2019. 5. Entitlement to SMC by reason of being housebound or based on the need of regular aid and attendance Under Akles v. Derwinski, the Board has jurisdiction over a claim for SMC as inferred based on the record. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). SMC is payable to individuals who are permanently bedridden or are so helpless as a result of service-connected disability as to be in need of the regular aid and attendance of another person under the criteria set forth in 38 C.F.R. § 3.352(a), 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b)(3). A veteran will be considered in need of regular aid and attendance if he or she: (1) 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 (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). 38 C.F.R. § 3.351(c). The following factors will be accorded consideration in determining the need for regular aid and attendance: inability of a claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustments of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of a claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, either physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). The particular personal functions that the veteran is unable to perform are considered in connection with the veteran’s 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 be a constant need. In Turco v. Brown, 9 Vet. App. 222, 224 (1996), the CAVC held that eligibility for SMC by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met. In addition, determinations that the claimant is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant’s circumstances are such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. 38 C.F.R. § 3.352(a). The Veteran has not contended, and the record does not show, that he is permanently bedridden. In addition, the evidence of record does not show that the Veteran was or is now in need of regular aid and attendance during the appeal period. There is no indication in the record that the Veteran was or is now incapable of dressing or undressing himself, keeping himself ordinarily clean and presentable, feeding himself through loss of coordination of upper extremities or through extreme weakness, attending to the wants of nature, was in frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability could not be done without aid or that he required care or assistance on a regular basis to protect him from hazards or dangers incident to her daily environment. The Veteran’s post-service treatment records document that for the entire appeal period, the Veteran reported the ability to independently perform all activities of daily living, including bathing, clothing and eating. The Board acknowledges that in VA treatment notes dated in March, June and September 2016, the Veteran was reported to have mild difficulty and to be mildly slowed in completing self-care activities, and that others had concerns about his safety and managing responsibilities living independently. Nonetheless, the Board finds these reports do not rise to the level of showing a need for regular aid and attendance, and that VA treatment records consistently show that the Veteran was able to perform basic living skills, he was neatly dressed and well-groomed and his speech and thought processes were logical and appropriate. See VA Treatment Reports dated from 2008 to 2019. In sum, the evidence of record does not show that the Veteran is unable to dress or undress himself or to keep himself ordinarily clean and presentable; that he is unable to feed himself through loss of coordination of upper extremities or through extreme weakness; that he is unable to attend to the wants of nature; or that he requires care or assistance on a regular basis to protect himself from hazards or dangers incident to his daily environment due to incapacity, either physical or mental. SMC at the housebound rate is available where a Veteran is in receipt of a 100 percent rating (or TDIU) based on a single disability and either (i) has additional disabilities independently rated at 60 percent or greater or (ii) is permanently housebound by reason of service-connected disability or disabilities. 38 C.F.R. § 3.350 (i)(2). The Veteran’s TDIU is based on his service-connected acquired MDD. However, the Veteran does not have any additional service-connected disability rated at 60 percent or greater that is separate and distinct from the TDIU. As noted above, the Veteran’s other service-connected disorders include migraine headaches, TBI, TMJ, low back strain, tinnitus, left malar complex fracture and gastritis, and none of these are independently ratable at 60 percent or more. In addition, the Veteran has not contended, and the record does not show, that his service-connected disabilities render him housebound. The Veteran therefore does meet the regulatory requirements regarding SMC based on housebound. Based on the foregoing, the Board finds that entitlement to SMC based on the need for regular aid and attendance or being housebound is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. The preponderance of the evidence is against the claim of entitlement to SMC. As such, that doctrine is not applicable and the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Battaile 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.