Citation Nr: 1631882 Decision Date: 08/10/16 Archive Date: 08/23/16 DOCKET NO. 16-15 888 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for lumbosacral strain. 2. Entitlement to service connection for hyperlipidemia. 3. Entitlement to an initial rating in excess of 70 percent for a psychotic disorder, to include a total rating based on individual unemployability due to service-connected disability (TDIU). ATTORNEY FOR THE BOARD K. Conner, Counsel INTRODUCTION The appellant served on active duty from April 2001 to February 2006. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In a November 2007 rating decision, the RO, inter alia, denied service connection for hyperlipidemia and a psychiatric disability. The RO also denied an initial rating in excess of 10 percent for lumbosacral strain. Before the appeal was certified to the Board, in a July 2010 rating decision, the RO granted service connection for a psychotic disorder, not otherwise specified (claimed as posttraumatic stress disorder (PTSD), adjustment disorder with anxiety and depression, and depression associated with lumbosacral strain) and assigned an initial 30 percent rating effective February 9, 2006, the day following the date of the appellant's separation from active service, and a 70 percent rating from November 21, 2008. The grant of service connection for a psychotic disorder constitutes a full award of the benefit sought on appeal with respect to the claim of service connection for a psychiatric disability. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). In May 2011, however, the appellant submitted a notice of disagreement with the initial rating assigned, arguing that the 70 percent rating was warranted from the date of his separation from service. At that time, he also claimed entitlement to a total rating based on individual unemployability due to service-connected disability. In an October 2012 rating decision, the RO denied a total rating based on individual unemployability due to service-connected disability, and the appellant appealed. Before the appeal was certified to the Board, in a January 2014 rating decision, the RO awarded an initial 70 percent rating for psychotic disorder, effective February 9, 2006, the day following the date of the appellant's separation from active service. In a January 2014 letter, the RO advised the appellant that its decision "is considered a full grant of benefits sought on appeal. Because of this increase no further action will be taken on this issue unless you express dissatisfaction with this decision." In April 2014, the appellant responded that he felt that he was entitled to a 100 percent disability rating, effective November 21, 2008, a date which apparently corresponds to a period of involuntary hospitalization for psychiatric treatment. Thereafter, in a March 2016 rating decision, the RO granted a total rating based on individual unemployability, effective May 10, 2011, the date of receipt of his application for that benefit. In a March 2016 letter, the RO advised the appellant that its action "is considered a full grant of benefits sought on appeal," and that "no further action will be taken on this issue unless you express dissatisfaction with this decision." In March 2016, the appellant indicated that he was seeking a 100 percent schedular rating from 2008. See Report of General Information, dated March 28, 2016. In April 2016, the RO responded by issuing a Statement of the Case addressing the following issues: "Entitlement to an evaluation for psychotic disorder not otherwise specified in excess of 70 percent from and following February 9, 2006;" and "The propriety of February 9, 2006, the day following your discharge from service, as the effective date of increase to 70 percent disabling for psychotic disorder, not otherwise specified." Later that month, the appellant responded that his appeal was for a 100 percent rating, effective February 9, 2006. See Report of General Information, dated April 25, 2016. In light of the procedural history of this case, and liberally interpreting the appellant's contentions, the Board finds that this appeal stems from the initial rating assigned following the award of service connection for a psychotic disorder. See e.g. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009) (holding that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, is part of the claim for an increased rating). Under these circumstances, and in the interests of clarity, the Board has recharacterized the issue on appeal as set forth on the cover page of this decision. Given the decision below awarding the maximum benefit available under the law, no prejudice to the appellant has resulted. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Board notes that the appellant was previously represented in this appeal by the Disabled American Veterans (DAV). In May 2009, however, the appellant revoked power of attorney in favor of DAV, and he has been unrepresented to date. As set forth below, in a May 2011 statement, the appellant indicated that he wished to withdraw his appeal with respect to the issues of entitlement to service connection for hyperlipidemia and an initial rating in excess of 10 percent for lumbosacral strain. Under these circumstances, these issues are no longer within the Board's jurisdiction. See Hamilton v. Brown, 4 Vet. App. 528 (1993) (en banc), aff'd, 39 F.3d 1574 (Fed. Cir. 1994) (holding that the Board is without the authority to proceed on an issue if the claimant indicates that consideration of that issue should cease). Accordingly, those issues have been dismissed below. In May 2016, the Board granted the appellant's request to advance his case on its docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. In May 2011, prior to the promulgation of a decision in the appeal, the appellant notified VA that he wanted to withdraw his appeal with respect to the issues of entitlement to service connection for hyperlipidemia and an initial rating in excess of 10 percent for lumbosacral strain. 2. The evidence is in equipoise as to whether the appellant's service-connected psychiatric disability has been productive of total occupational impairment since his separation from active service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal have been met with respect to the issues of entitlement to service connection for hyperlipidemia and an initial rating in excess of 10 percent for lumbosacral strain. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 2. The criteria for an initial 100 percent rating for a psychotic disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Under the VCAA, VA is required to advise a claimant of the information and evidence not of record that is necessary to substantiate a claim. See 38 U.S.C.A. § 5103 (West 2014); 38 C.F.R. § 3.159(b)(1) (2015). VA also has a duty to assist claimants in obtaining evidence needed to substantiate a claim, unless no reasonable possibility exists that such assistance would aid in substantiating that claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2015). In light of the favorable disposition below, the Board finds that any deficiency in VA's VCAA notice or development actions is harmless error with respect to the issue adjudicated in this decision. I. Hyperlipidemia and Lumbosacral Strain Under applicable criteria, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2014). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2015). Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, in a May 2011 statement, the appellant indicated that he wished to withdraw his appeal with respect to the issues of entitlement to service connection for hyperlipidemia and an initial rating in excess of 10 percent for lumbosacral strain. Hence, there remain no allegations of errors of fact or law for appellate consideration with respect to that claim. Accordingly, the Board does not have jurisdiction to review the appeal of this issue, and it is dismissed. II. Psychotic Disorder Background The appellant's service treatment records show that, in August 2004, he was involved in a motor vehicle accident in which he was rear-ended by a truck. Following the accident, the appellant underwent a trauma workup, which was negative. He was diagnosed as having a neck and back strain and prescribed analgesics. Subsequent service treatment records, however, show that the appellant thereafter sought treatment on a regular basis for complaints of persistent pain, including neck, low back, and radicular pain. Initial treatment included physical therapy and narcotics, which proved ineffective. He was then referred to a pain clinic. Pain clinic records show that the appellant was subsequently diagnosed as having an adjustment disorder with anxiety and a prolonged depressed mood. In May 2005, a Medical Evaluation Board (MEB) determined that the appellant was unable to successfully perform his military duties as a result of chronic mechanical neck and low back pain. It was also noted that the appellant's medical problems had significantly impacted his personal life by limiting his hobbies, interrupting normal sleep patterns, and making activities of daily living difficult. The MEB determined that the appellant was likely to require ongoing therapy and medical follow-up by clinicians specializing in neck and back rehabilitation and pain management. In February 2006, shortly prior to his separation from active duty, the appellant underwent a psychiatric examination in the pain rehabilitation clinic. At that time, his mood was noted to be despairing, anxious, and angry. His affect was constricted, agitated, angry, and showed worry. Connectedness was deficient showing circumferentality. He had racing thoughts and paranoid ideation with a belief that his command was out to get him. His appetite and energy level were decreased, and he exhibited early insomnia. There was no suicidal or homicidal ideation. The assessments included a pain disorder associated with psychological and physical factors. The examiner noted that, as the appellant was exiting the military, he had reported an exacerbation of chronic intense stress over perceived mistreatment, which had been a thematic pattern since the onset of his pain resulting in an increased arousal tension and pain. The examiner further noted that the appellant's projection of anger onto his command was a focus of ruminative worry with resultant feelings of powerlessness and helplessness fueling a psychophysiological cycle which heightened pain perception. On February 24, 2006, VA received the appellant's original application for VA compensation benefits, seeking service connection for multiple disabilities, including a mental condition. VA clinical records received in support of the claim show that the appellant sought to establish care with VA in March 2006. With respect to psychiatric symptoms, the appellant reported that he was under high stress and was currently not feeling comfortable to work. He denied having depression, but reported feeling "bummed out." He reported that he felt afraid to go out and do things for fear of hurting his back. The diagnoses included an adjustment disorder with anxiety and depressed mood. In support of his claim, the appellant was afforded a VA medical examination in April 2006 at which time the examiner concluded that the appellant did not have a current psychiatric problem. In reviewing the record, the examiner noted that, although some providers thought the appellant had had an adjustment disorder following an in-service car accident, there was no current evidence of any ongoing psychiatric symptoms. The Axis I diagnosis was "no psychiatric diagnosis." The examiner assigned a Global Assessment of Functioning (GAF) of 75 over the past year. In a July 2006 rating decision, the RO, inter alia, denied service connection for an adjustment disorder with anxiety and depression, finding that the record showed that the appellant did not have a current psychiatric disability. Subsequent VA clinical records received show that, at a follow-up VA appointment in July 2006, the appellant reported that he had been depressed. He also indicated that was unable to trust anyone anymore due to being "sabotaged" in the military by a comrade who "ruined his inspection." The impressions included depression. The appellant was given a consultation for counseling. According to a July 2006 consultation note completed by a VA social worker, during a telephone conversation with the appellant, things "became complicated and involved" when the appellant implied that some kind of "criminal" activity had been perpetrated against him while he was on active duty, particularly that his evaluations with psychiatric personnel had been distorted and misconstrued. The appellant reported that this had resulted in his being very mistrustful of care providers and fearful of it happening again. He therefore required that his consultations be taped and transcribed exactly. The VA social worker noted that, after a 25 minute phone conversation attempting to negotiate with the appellant, he concluded that did not wish to receive treatment from the social worker. In September 2007, the appellant was afforded another VA medical examination. He reported car accidents in 2004 and again in 2007 and indicated that he remained under treatment for back, neck, and leg pain associated with a motor vehicle accident. He indicated that he was very depressed as a result of his pain. He also reported a traumatic experience in service, but did not want to provide details. An examination showed no evidence of hallucinations, delusions, or impairment of thought process or communication. The examiner concluded that the appellant's psychiatric symptoms were moderate in severity and occurred sporadically. The diagnosis was depressive disorder secondary to physical problems due to a January 2007 motor vehicle. A GAF of 55 was assigned. In a November 2007 rating decision, the RO denied service connection for depression, finding that the appellant's psychiatric disability was secondary to physical problems caused by a post-service motor vehicle accident. The appellant perfected an appeal of the RO's determination, arguing that he had had a psychiatric disability since service. Additional pertinent records thereafter assembled in support of the appellant's claim include VA clinical records showing that, at a December 2007 VA medical appointment, it was noted that the appellant was crying from the stress of his divorce. He described his wife as emotionally and physically abusive and distant. He also reported a history of head trauma in service when he was assaulted. He claimed that documentation of the incident, however, had been shredded to protect the perpetrator. He noted difficulty in communicating with his superior officers and military physicians. The diagnoses included dysthymia. Private clinical records show that, in November 2008, the appellant was hospitalized after he apparently overdosed on Vicodin and Flexeril. He denied any previous suicidal attempts. On initial psychiatric evaluation, there was no significant psychomotor agitation or retardation. His speech was productive within normal rate, tone, and volume. The appellant was very articulate, and his mood was neutral with a full affect. His thought process was mostly linear and logical, and his thought content was free of any suicidal or homicidal ideations. The examiner indicated that there were no delusions or hallucinations elicited, and the appellant was alert and oriented times three. The impression was adjustment disorder with behavioral disturbance, rule out major depression. A GAF score of 35 to 40 on admission was assigned. On further evaluation, however, the examiner indicated that the appellant was a poor and unreliable historian. He was able to recall very detailed information regarding his medical diagnoses and treatment, but had no recollection of his reason for hospitalization. The examiner indicated that there was a conflict between emergency room records and the appellant's interview and noted that collateral information was required. The appellant improved with treatment and was discharged in December 2008 with instructions to follow-up on an outpatient basis. The diagnoses on discharge were adjustment disorder with behavior disturbance, rule out major depression. In May 2009, the appellant was again brought to the emergency room after his mother raised concerns about suicidal statements that the appellant had made. His sister also reported that the appellant had been acting bizarrely. On admission, the appellant was defensive and denied all accounts of his mother's concern. Despite the reports of his family, the appellant denied feeling suicidal, making any suicidal statements in the past, and experiencing any auditory or visual hallucinations. He denied paranoid thoughts and problems with sleep, appetite, or energy level. The examiner, however, noted that the appellant claimed that there were cameras in his apartment and that he was being monitored. He also talked in a disorganized manner and exhibited significant psychomotor agitation. His thought content was significant for delusions of paranoia and persecution. The appellant was admitted in restraints due to emergent aggressive violent behavior. On subsequent examination during the course of admission, the appellant again denied having auditory hallucinations, visual hallucinations, or other psychotic symptoms. He denied having suicidal thoughts or mood disturbances other than feeling frustrated at being admitted involuntarily. The appellant also denied having a mental illness and continued to deny the history given by friends and family who had observed psychotic behaviors and suicidal gestures in the past. The medical staff noted that the appellant continued to be paranoid and somewhat intrusive. The appellant was described as superficially cooperative, but challenging at times and required frequent redirection. His mood was irritable with labile affect at times. His thought process was linear and logical, but his thought content was significant for delusions of paranoid and persecution. No suicidal ideations were elicited, and there were no homicidal ideations, auditory hallucinations, or visual hallucinations. His insight and judgment were impaired. The impression was schizophrenia of paranoid type, and a GAF score of 40 was assigned. The examiner recommended court ordered treatment for mandatory outpatient commitment or possible long-term hospitalization. On follow-up examination in June 2009, the appellant was noted to be compliant with treatment. He was social, and there was no evidence of psychosis. The appellant reported that he was feeling good and denied feeling depressed, hopeless, or helpless. He indicated that he was sleeping and eating well. Examination showed no racing thoughts, auditory or visual hallucinations, or delusions. He also denied having suicidal ideation, homicidal ideation, or plans. He was alert, awake, and oriented times three. He was also calm, pleasant, cooperative, and made good eye contact. His mood was good, his affect was restricted, his speech was soft and spontaneous, and his thought process and content were logical and goal-directed. The appellant exhibited no psychosis, suicidal ideation, or homicidal ideation or plan. It was felt that the appellant's pain medication may have been contributing to his psychosis. The diagnoses on discharge included psychosis, not otherwise specified, rule out schizophrenia. A GAF of 30 to35 was assigned. VA clinical records show that, in May 2009, the appellant walked into the mental health clinic and asked to be seen by a psychiatrist urgently for medications. He expressed that he had passive suicidal ideation at times, wishing God would just take him. He was very tangential and almost loose and somewhat difficult to understand, but then he was able to pull himself together and be more coherent. He alluded to being exploited by the adult children of his girlfriend, but was not clear on what they were doing. He indicated that he had "called some officials on them." The appellant stated that he had not been able to work due to his chronic neck injury and pain. He was very loquacious, and his thought content was preoccupied with wanting to discuss what he was dealing with and obtaining medication to relieve his depression and anxiety. He denied hallucinations, but did speak of being poisoned by the water of Cedar Lake. He also referenced something regarding an eye dropper poisoning him and someone doing something called "window tapping" to him, but he could not explain a motive. The examiner described the appellant as "fragmented." The impression was mood disorder, not otherwise specified, and anxiety, not otherwise specified, consider PTSD and rule out psychosis. A GAF score of 45 was assigned. According to subsequent VA clinical records, in June 2009, a physician from the private facility where the appellant had been hospitalized advised VA that the appellant had recently been admitted for schizophrenia. The physician noted that he believed that the appellant's pain medications may have been contributing to his psychosis. On examination later that month, the appellant refused to sign a consent for the release of his private hospitalization records. He denied suicidal ideation and paranoia, but stated that he thought he had been sexually assaulted when he was in the hospital and was very mistrusting and reserved. He denied having auditory or visual hallucinations. A GAF score of 45 was assigned. At a follow-up appointment later that month, the examiner recommended that the appellant consider a day hospital program for intensive treatment, but the appellant deferred. According to a June 2009 treatment plan note, the appellant's psychiatric diagnoses included psychotic disorder, not otherwise specified, paranoid type, chronic persecutory type without good prognostic features, as manifested by various symptoms including delusions, odd beliefs, impaired reality testing, inflated self-esteem or grandiosity, a suicide attempt, digressive speech, an inappropriate affect, and emotional turmoil. The long-term goals included reducing his psychotic symptoms, suicidal ideation, and delusional thinking. In an August 2009 letter, a VA physician indicated that the appellant had been under his care since May 2009 for multiple conditions, including psychosis, mood disorder, and anxiety not otherwise specified, consider PTSD with severe paranoia. VA clinical records show that, in September 2009, the appellant's psychiatrist noted that she had received an urgent phone call from the appellant's sister who expressed concern regarding his safety and the safety of others. The appellant was swerving on the road while driving, had not eaten food for five days, and was sleeping very heavily. Later that day, the appellant was evaluated, and in-patient psychiatric hospitalization was recommended due to his increased agitated behavior and concern that he was either abusing substances or over-sedated from his medications. He refused. In October 2009, the appellant was evaluated in an outpatient setting. He reported suicidal ideation, which came and went fleetingly and was mostly of a passive nature. He was very stressed financially and continued to experience ongoing difficulties with anger management in the context of anxiety and paranoia. On examination in December 2009, the appellant reported that he thought he should work, but did not feel he would be able to tolerate the stressors of work. The appellant's mood was mildly depressed, and his affect was blunted but polite and appropriate. There were no suicidal or homicidal ideations, nor were there any auditory or visual hallucinations. The appellant was paranoid and guarded at times. The impressions included depressive disorder and psychosis not otherwise specified, consider paranoid schizophrenia and PTSD. In March 2010, the appellant reported that he had been attending school, but missed classes due to forgetting to take his medications. He described what appeared to be an auditory hallucination, but denied that he might have experienced it. The impressions included psychosis not otherwise specified, consider schizophrenia versus delusional disorder; and consider PTSD, severe with paranoia. The examiner noted that the appellant was a high risk for suicide. The appellant underwent another VA medical examination in May 2010. He indicated that he had not worked since service and was afraid to go to work, as he did not want "the same thing to happen as when I was in the service," including treason and being threatened by people who felt he was performing better than everyone else. The appellant reported feeling sad daily and having weekly crying spells, decreased concentration, and sleeping difficulties. He indicated that he was bothered by feelings of insecurity and inferiority. He sometimes thought that he would be better off dead than alive, but denied wanting to take his own life. A mental status examination showed that the appellant did not appear to be experiencing any auditory or visual hallucinations, although at times he seemed to miss the point, and it was unclear whether this was a thinking problem or an attention problem. After examining the appellant, the examiner diagnosed him as having a psychotic disorder and assigned a GAF score of 51. She concluded that the appellant's psychiatric disorder was related to military service. In a July 2010 rating decision, the RO granted service connection for a psychotic disorder, not otherwise specified (claimed as PTSD, adjustment disorder with anxiety and depression, depression associated with lumbosacral strain) and assigned an initial 30 percent rating effective February 9, 2006, the day following the date of the appellant's separation from active service. The RO also assigned a 70 percent rating from November 21, 2008. In May 2011, the appellant initiated an appeal of the RO's determination, arguing that the record supported the assignment of a 70 percent rating from the date of his service separation. He also claimed entitlement to a total rating based on individual unemployability due to service-connected disability. In support of his claim, the appellant submitted a completed VA Form 21-8940 on which he reported that he had been unable to work full-time since February 2006. He indicated that he had worked approximately 10 hours per week doing odd jobs between September 2006 and February 2007, but had had no other post-service employment. Additional VA clinical records obtained in support of the claim showed continued treatment for mood symptoms, paranoia, psychosis, and severe anxiety. Between 2010 and 2012, with one exception, examiners consistently assigned a GAF score of 50. During a VA medical examination in July 2012, the appellant displayed suspiciousness, impaired judgment, and abstract thinking. He remained unemployed. The examiner indicated that the appellant may be able to obtain gainful employment, although as a result of his service-connected psychiatric disability, "[h]e may be unable to maintain it without making significant changes in his daily routine." The examiner noted that the appellant's attention to hygiene and clothing changes could also prove challenging to co-workers. Additional VA clinical records obtained in support of the claim showed continued treatment for psychiatric symptomatology, including depression, anxiety, paranoia, and a high risk of suicide. Between 2012 and 2014, the appellant was again consistently assigned a GAF score of 50. Applicable Law Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10 (2015). 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 (2015). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2015). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The criteria for rating psychotic disorders are contained in the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9210. Under those criteria, a 70 percent rating is assigned when there is objective evidence demonstrating 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, or 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. 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 and place, memory loss for names of close relatives, own occupation, or own name. In Mauerhan v. Principi, 16 Vet. App. 436 (2002), the U.S. Court of Appeals for Veterans Claims (Court) held that use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the evidence considered in determining the level of impairment under section 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. More recently, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed.Cir 2013). The Federal Circuit explained that in the context of a 70 percent rating, section 4.130 "requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. at 118. The Federal Circuit indicated that "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. A Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV)). Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Lesser scores reflect increasingly severe levels of mental impairment. Id. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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(b) (West 2014); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis Applying the criteria set forth above to the facts in this case and affording the appellant the benefit of the doubt, the Board finds that his service-connected psychotic disorder has been productive of symptomatology which more nearly approximates the criteria for 100 percent disability rating since the effective date of the award of service connection. In reviewing the General Rating Formula for Mental Disorders, the Board observes that the appellant exhibits many symptoms specifically delineated in criteria for a 70 disability rating. For example, he exhibits social impairment, suicidal ideation, depression, significant difficulties adapting to stressful circumstances, and impaired judgment. The record on appeal, however, also shows that the appellant exhibits symptoms delineated in the criteria for a 100 percent disability rating, including persistent delusions, impairment in thought processes, and inappropriate behavior. As set forth above, the record further demonstrates that treatment providers have determined that he is a high suicide risk, thereby presenting a danger to hurting himself. In addition, the record shows that the appellant's behavior has raised concerns about the possibility of him harming others. As noted above, his family has expressed concern regarding both his safety and the safety of others in light of the appellant's erratic driving. Indeed, he has a history of automobile accidents, an involuntary commitment, and clinical records document recommendations for additional intensive treatment. He has also exhibited an intermittent inability to perform activities of daily living. Moreover, he has a history of failing to eat, and a VA examiner has noted that the appellant's hygiene and clothing choices may present a barrier to maintaining gainful employment. In addition to these specifically delineated symptoms, the record also demonstrates that the appellant's psychotic disorder has been manifested by significant and longstanding delusions, impaired reality testing, and emotional turmoil. He has not held full-time employment since service separation. During the period in question, treatment providers have assigned GAF scores primarily of 50 and below, reflecting serious impairment in social or occupational functioning, including the inability to keep a job. Although the record does contain evidence suggesting that the appellant's psychotic disorder has not been consistently productive of total occupational impairment since service separation, in cases such as this, where there is a question as to which of two evaluations apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2015). Affording the appellant the benefit of the doubt, the Board concludes that the appellant's disability picture more nearly approximates the criteria for an initial 100 percent schedular rating. ORDER The appeal for the issue of entitlement to service connection for hyperlipidemia is dismissed. The appeal for the issue of entitlement to an initial rating in excess of 10 percent for lumbosacral strain is dismissed. A 100 percent rating for PTSD is granted, subject to the law and regulations governing the payment of monetary benefits. ______________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs