Citation Nr: 21025364 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 10-32 936 DATE: April 28, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is granted. Entitlement to a disability rating of 70 percent, but no higher, for dysthymic disorder for the entire appeal period is granted. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, the Veteran’s OSA onset in active service. 2. For the entire period on appeal, the Veteran’s dysthymic disorder resulted in an occupational and social impairment with deficiencies in most areas of work, school, family relations, judgment, thinking and mood, but not total occupational and social impairment. 3. The Veteran’s dysthymic disorder symptoms preclude him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for OSA have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to a 70 percent disability rating, but no higher, for dysthymic disorder for the entire appeal period have been met. 38 U.S.C. §§ 1110, 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.126, 4.130, Diagnostic Code 9433. 3. The criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service with the U.S. Army from October 1973 to July 1975, from September to December 1994, from January to October 2002, and from February 2003 to December 2004. He died in February 2019, during the pendency of his appeal. The appellant, the Veteran’s widow, has been recognized as the substitute claimant pursuant to 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010(b). Specifically, the appellant submitted VA Form 21-0847 in May 2019. In May 2019, the RO personnel recognized the appellant as a proper substitute of the deceased Veteran based on relationship. In essence, the appellant is entitled to pursue all pending matters as if she were the Veteran, with the same rights and responsibilities. These matters come to the Board of Veteran’s Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. A January 2018 letter from the Veteran’s representative withdrew all prior hearing requests. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits.  38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a).  These duties have been satisfied in this case.  Appropriate notice was provided in May 2019.  The RO associated the Veteran’s service and VA and private outpatient treatment records with the claims file. All released or submitted private treatment records have been associated with the claims file. No other relevant records have been identified and are outstanding.  Appropriate and necessary medical opinions were obtained and are adequate for evaluation, as they include needed findings to permit application of the rating schedule and identification of current disability. Such includes the medical opinion ordered in the March 2018 Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). As such, VA has satisfied its duty to assist. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (2018). Moreover, the United States Court of Appeals for Veterans Claims (CAVC) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The Veteran contends that his OSA is related to his active duty service. The Veteran’s service treatment records (STRs) were silent for a diagnosis or treatment for OSA. However, a February 2004 report of medical history shows that the Veteran reported frequent trouble sleeping. Post-service treatment records documented that the Veteran was diagnosed and treated for OSA. In July 2011, the Veteran reported poor sleep and heavy snoring, causing problems with his wife. He was scheduled for a sleep study and a November 2011 sleep study demonstrates that the Veteran was diagnosed with OSA. In December 2014 statements (received January 2015), EV and HR noted that they served with the Veteran. They both indicated that they witnessed the Veteran snore and gasp for air while sleeping. In January 2021, a VA medical opinion was obtained. The examiner noted that the Veteran was diagnosed with OSA with an onset date of November 2011. The examiner opined that the Veteran’s OSA was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Her rationale was that the record was silent for chronicity of care, complaint, and/or evaluation during active service. She noted that there was no treatment within two years after his discharge. She indicated that the Veteran was diagnosed with OSA in November 2011 several years after his discharge. She noted that buddy statements were submitted that indicated that the Veteran snored and stopped breathing in his sleep during his service. However, she stated that the records did not document those sleep problems. She indicated that there was no proof without speculation that the alleged signs and symptoms were due to his OSA at that time. Upon review of the evidence of record, the Board finds the lay statements of the Veteran and his fellow servicemen competent and credible as to the Veteran’s sleep symptoms during active service. Those statements coupled with the Veteran’s report of frequent trouble sleeping on separation from active service, and the reason given for obtaining a sleep study, i.e. heavily snoring which was reportedly present during service and supported the diagnosis of sleep apnea, weighs in favor of a grant of service connection. Though the VA examiner provided a negative etiology opinion, the examiner discounted the lay statements based on no evidence in the service treatment records and no treatment within two years of service which lessens the probative value of that opinion. Resolving reasonable doubt in the Veteran’s favor, service connection for sleep apnea is granted. Increased Rating Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and, above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran’s dysthymic disorder is evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Code 9433. The Veteran is currently rated 30 percent disabled. A 30 percent disability rating is warranted when there is an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent disability rating is warranted when there is an 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. Id. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. Finally, a 100 percent disability 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. An April 2009 VA treatment note documented that the Veteran had a depressed mood and shallow affect. He talked in a soft tone voice. The Veteran denied suicidal or homicidal ideations. He was oriented to person, place, and time. The Veteran had good judgment and had fair to good insight. In August 2009, the Veteran was afforded a VA examination. The Veteran reported that he wanted to be by himself at night. He indicated that he had sleep difficulties. He reported that he had feelings of hopelessness and helplessness described as moderate. There was mild to moderate psychomotor retardation and restricted affect. The Veteran was currently employed fulltime. His speech was unremarkable. His attitude was constricted. His mood was anxious and depressed. He was oriented to person, place, and time. His thought process, content, and judgment were intact. He denied any delusions or hallucinations. He did not have any inappropriate behavior. He did not have obsessive/ritualistic behavior or panic attacks. He denied any homicidal or suicidal thoughts. He had good impulse control. He was able to maintain minimum personal hygiene. The Veteran did not have problems with activities of daily living. His remote and recent memory was normal. However, his immediate memory was severely impaired. The examiner noted that he was unable to recall any words after 5-minute delay. The examiner opined that the Veteran’s mental disorder resulted in deficiencies in judgement, thinking, family relations, work, mood, or school. A May 2012 VA treatment note documented that the examiner recommended hospitalization for the safety of the Veteran and his family members. The Veteran reported that he was more irritable and was afraid that he would lose control and become aggressive. The Veteran felt that he needed be to be isolated from his family for some time to avoid a bad situation. A May 2012 private treatment note documented that he was admitted with severe recurring major depression. The Veteran responded positively to treatment. The Veteran had signs and symptoms of anxiety, depression, and resentment. In January 2013, the Veteran was afforded a VA examination. The Veteran was diagnosed with dysthymic disorder. The Veteran was retired from a governmental agency. He was eligible by age and duration of work. The Veteran had trouble sleeping with frequent awakenings and restlessness. The Veteran had two psychiatric hospitalizations, one partial and one inpatient. The Veteran had symptoms of depressed mood and anxiety. The examiner opined that the Veteran’s mental disorder caused an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. A December 2014 VA treatment note documented that the Veteran was in inpatient psychiatric hospitalization after he expressed having suicidal ideation with an active plan. The Veteran now reliably denied any suicidal or homicidal ideation or intentions. He denied any auditory or visual hallucinations or any other psychotic symptoms. The Veteran reported that he was feeling better and was interacting with people. His mood and affect were euthymic and congruent. The Veteran was now stable from his acute symptoms. A February 2015 VA treatment note documented that the Veteran was seen for his dysthymic disorder. The examiner noted that the Veteran was admitted due to exacerbation in depressive symptoms and suicidal ideas. The Veteran admitted previous suicidal attempts. The Veteran now had good compliance with his treatment. The Veteran reported that he had nightmares and flashbacks as his main stressors. The Veteran had apposite hygiene. He made adequate eye contact during the examination. The Veteran was alert and made full contact with reality. The Veteran was goal directed. He was oriented to person, place, and time. His judgment and insight were logical. He had good judgment and insight. He denied suicidal or homicidal ideations. He denied hallucinations. The Veteran reported that the he had loss of interest in activities, poor concentration, decreased appetite, loss of energy, crying spells and trouble sleeping at night. He noted that he had a feeling of worthlessness, uselessness, and hopelessness. A December 2015 VA treatment note documented that the Veteran was seen for a follow up visit. The Veteran reported that he got very depressed and had suicidal ideation. He was admitted to the P. Hospital inpatient unit in November and was discharged December 2, 2015. A February 2016 VA treatment note documented that the Veteran was seen for his dysthymic disorder. The Veteran reported that he felt depressed. He indicated that he had symptoms of depression, anxiety, sleep problems, nightmares, heard voices, poor energy, and loss of interest in daily activities. During the interview, the Veteran exhibited adequate hygiene, appropriate eye contact, full contact with reality, and was communicative. The Veteran’s judgment and insight was normal. The Veteran was calm, cooperative, alert, oriented, coherent, and depressed. The Veteran was oriented to person, place, and time. He denied suicidal or homicidal ideations. In November 2016, the Veteran was afforded a VA examination. The Veteran was diagnosed with dysthymic disorder. The Veteran lived with his third wife. There was no history of hospitalization or emotional crisis since 2014. There was no history of illegal problems, civil problems, criminal accusations, or any behavioral disturbances. During the evaluation the Veteran behaved properly. He was well developed, well-nourished, and appropriately dressed. The Veteran had adequate hygiene. He was cooperative during the evaluation. He was alert and in contact with reality. His speech was normal and thought process was logical. He made good eye contact with the examiner. There was no disorganized speech or phobias. His mood was anxious, and affect was appropriate. He denied any hallucinations and delusions. He denied having any panic attacks. He denied suicidal or homicidal ideation. He was oriented to person, place, and time. His memory was intact. The Veteran’s judgment was good, and insight was adequate. The Veteran had symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood. The examiner opined that the Veteran’s mental disorder caused an occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Board notes that this examination was found inadequate, but the Board will still consider favorable findings made on examination. A December 2017 VA treatment note documented that the Veteran completed inpatient treatment for suicidal ideation. An April 2017 VA treatment note documented that the Veteran was seen for treatment. The Veteran reported that he heard voices calling him. The Veteran indicated that he had anhedonia and low tolerance. He had adequate hygiene and was appropriately dressed for his appointment. His attitude was cooperative, and his speech was slow. He was alert and attentive. The Veteran was oriented to person, place, and time. He had feelings of worthlessness and obsessions. He had auditory hallucinations. The Veteran had poor recent memory. He had limited insight and judgement. The Veteran denied any suicidal or homicidal ideations. A November 2017 VA treatment note documented that he continued to have anhedonia, dysphoric with compromised judgment and apparent confabulation, especially towards his wife. The Veteran reported suicidality and he agreed to be admitted to inpatient unit at P.A. Hospital. The examiner noted that compared to the Veteran’s last visit he showed significant worsening. An August 2018 VA treatment note documented that the Veteran had overvalued ideas and obsessions. The Veteran had limited insight. He had recent and immediate memory difficulties. A May 2018 VA treatment note document that the Veteran was seen for treatment. The Veteran reported that in the past there was protection order against him from his first wife. In January 2021, a VA medical opinion was obtained. The VA examiner noted that she reviewed the Veteran’s claims file. She noted that she reviewed the Veteran’s hospitalizations and medical treatment from 2014 to 2016. She indicated that the Veteran had symptoms of anxiety, chronic sleep impairment, and disturbances of motivation and mood. She opined that the Veteran’s mental disorder caused an occupations and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. Based upon the evidence of record, the Board finds that the evidence shows that his disability picture more nearly approximates the level of severity contemplated by a 70 percent rating for dysthymic disorder, which contemplates impairment in most areas. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9433. The Veteran has exhibited a social and occupational impairment in most areas with symptoms such as depressed mood, anxiety, anger with irritability, chronic sleep impairment, disturbances of motivation and mood, overvalued ideas and obsessions, poor memory, hallucination, and suicidal ideation. Notably, the Veteran was admitted in May 2012 and December 2014 for suicidal ideation and the safety of himself and family members. A February 2016 VA treatment note documented that the Veteran reported that he heard voices and had poor energy. A November 2017 VA treatment note documented that the Veteran had compromised judgment and apparent confabulation towards his wife. Furthermore, the Veteran was admitted again in November 2017 for suicidal ideation. While the severity of the Veteran’s dysthymic disorder rises to the level envisioned by the 70 percent rating threshold, the Veteran does not display a manifestation of symptoms with the severity, frequency, and duration comparable of a 100 percent disability rating. While the Board recognizes that the Veteran had been hospitalized for safety related to himself and family members and 2017 and 2018 VA treatment records include several reports of hallucinations, the evidence does not reflect persistent delusions or hallucinations. The VA examination reports do not reflect evidence of persistent delusions or hallucinations and have not found that the Veteran’s symptoms are more akin to total occupational and social impairment. The overall evidence does not show gross impairment in thought processes or communication, persistent delusions or hallucinations; grossly inappropriate behavior, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. The Board finds that the Veteran’s symptoms are more akin to the severity, frequency, and duration of those in the criteria for a 70 percent rating. Accordingly, to the extent that the Board has denied a 100 percent rating, a preponderance of the evidence is against the claim and the claim for a rating in excess of 70 percent is denied. TDIU TDIU is granted where service-connected disabilities are so severe that the Veteran is unable to secure or follow a substantially gainful occupation. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. The central inquiry is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Consideration is given to the Veteran’s level of education, special training, and previous work experience. Van Hoose v. Brown, 4 Vet. App. 361 (1993); 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran meets the schedular criteria for TDIU pursuant to 38 C.F.R. § 4.16 (a). He has service-connected disability that meets the numeric standard and sufficient physical and mental limitations to preclude substantially gainful employment. The Veteran is service-connected disability ratings are as follows: 70 percent for dysthymic disorder (as a result of this Board decision) effective May 8, 2012, 30 percent for residual neuralgia status post herpetic keratitis, 10 percent for lumbar myositis, 10 percent for hypertension, and noncompensable (0 percent) for hiatal hernia. On January 2010 VA 21-8940, the Veteran indicated that his disability affected his full-time employment since October 2009. He indicated that he had some college eduction. The record reflected that the Veteran worked in maintenance and security for a governmental agency. As stated above, the Veteran was admitted for suicidal ideation in 2012, 2014, 2015, and 2017. Throughout the appeals period the Veteran had symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, overvalued ideas and obsessions, poor memory, and suicidal ideation. VA medical treatment records also reflected that the Veteran had some legal problems in April 2015 and has had several reports of behavioral disturbances, suicidal ideations, and hallucinations. An April 2017 VA treatment note documented that the Veteran heard voices. The examiner noted that the Veteran had poor recent memory and limited insight and judgement. Later in November 2017, the VA examiner noted that compared to the Veteran’s last visits he showed significant worsening. An August 2018 VA treatment note documented that he had overvalued ideas and obsessions and had limited insight. While such impairment is not total under the schedular criteria, it is clear that the Veteran’s dysthymic disorder would prevent the Veteran from functioning effectively in any work environment. The Board finds him unemployable based on his dysthymic disorder. Entitlement to a finding of TDIU is granted. There is no need to discuss entitlement to special monthly compensation (SMC) on a statutory housebound basis or based on a need for regular aid and attendance. While the Veteran is now in receipt of TDIU based on a single service-connected disability, he does not have any other additional conditions (aside from his dysthymic disorder) ratable at 60 percent disabling or greater. JESSICA SEAY Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Baxter 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.