Citation Nr: 1802521 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 01-05 227A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased rating for chronic musculoskeletal low back pain with dorsal column stimulator implant, currently rated as 40 percent disabling from April 12, 2007; 40 percent from November 1, 2007; 60 percent from January 1, 2008; and 40 percent from August 1, 2015. 2. Entitlement to a disability rating higher than 10 percent for radiculopathy of the left lower extremity for the period beginning on May 4, 2011. 3. Entitlement to a disability rating higher than 10 percent for radiculopathy of the right lower extremity for the period beginning on May 4, 2011. 4. Entitlement to an increased rating for schizoaffective disorder and major depressive disorder with psychotic features, currently rated as 40 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD C.S. De Leo, Associate Counsel INTRODUCTION The Veteran served in the Florida Army National Guard with periods of active duty for training (ACDUTRA) and inactive duty training (IDT), including one such period from October 1980 to May 1981. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran presented testimony at an August 2002 videoconference hearing before a Board Veterans Law Judge (VLJ). A transcript of the hearing is of record. The Veteran was notified that this VLJ had retired from the Board, and was given the opportunity for another hearing. In an April 2006 statement, he declined another hearing. In October 2003, September 2006, and August 2008, the Board remanded the low back disability claim for additional development. In a May 2011 Board decision, the Board found that the Veteran's low back disability merited a 20 percent rating prior to April 11, 2007, and remanded his claim of entitlement to an increased rating for low back disability from April 12, 2007 for further development. In that May 2011 decision, the Board granted separate 10 percent disability ratings for mild incomplete paralysis of the sciatic nerve of each lower extremity and assigned effective dates of September 23, 2002 for the ratings. That determination was final as of May 3, 2011, the date of the Board decision. The May 2011 Board decision also remanded the Veteran's claim for a total disability rating based on individual unemployability (TDIU) for further development. In April 2016, the Board granted a 40 percent rating for the psychiatric disorders and a total rating based on TDIU, and remanded for examination to determine the severity of the Veteran's disability because the 40 percent rating was not a full grant of the benefit sought. This case has been before the Board several times, and its history has been summarized in previous Board decisions. More recently, in April 2017, the Board remanded the issues on appeal. For the reasons discussed below, the Board finds that there has been substantial compliance with the development sought as part of the April 2017 remand. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. From April 12, 2007 to the present, the Veteran has not had ankylosis of the thoracolumbar spine or incapacitating episodes with a total duration of at least 4 weeks during a 12 month period. 2. The Veteran's radiculopathy of the left lower extremity has not resulted in more than mild incomplete paralysis of the left sciatic nerve. 3. The Veteran's radiculopathy of the right lower extremity has not resulted in more than mild incomplete paralysis of the right sciatic nerve 4. Throughout the appeal period, the symptoms and overall impairment caused by the Veteran's schizoaffective disorder and major depressive disorder with psychotic features more nearly approximate occupational and social impairment with deficiencies in most areas but do not more nearly approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. From April 12, 2007 to December 31, 2007, with exception of the period from September 4, 2007 to October 31, 2007, and November 21, 2007 to December 31, 2007, when a 100 percent temporary disability was awarded, the criteria for a disability rating in excess of 40 percent for musculoskeletal low back pain with dorsal column stimulator implant have not all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2017). 2. From January 1, 2008 to July 31, 2015, the criteria for a disability rating in excess of 60 percent for musculoskeletal low back pain with dorsal column stimulator implant have not all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21,, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2017). 3. From August 1, 2015, the criteria for a disability rating in excess of 40 percent for musculoskeletal low back pain with dorsal column stimulator implant have not all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21,, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2017). 4. The criteria for a disability rating higher than 10 percent for radiculopathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.130, Diagnostic Codes 9211, 9434 (2017). 5. The criteria for a disability rating higher than 10 percent for radiculopathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.130, Diagnostic Codes 9211, 9434 (2017). 6. The criteria for a disability rating of 40 percent, but no higher, for schizoaffective disorder and major depressive disorder with psychotic features have been met from February 10, 2003. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21,, 4.130, Diagnostic Codes 9211, 9434 (2017). This rating is assigned based on a 70 percent rating from the rating criteria, with a 30 percent historical offset outlined in the initial rating decision REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See eg. 38 U.S.C. §§ 5103, 5103A (2012) and 38 C.F.R. § 3.159 (2017). In the instant case, VA provided adequate notice in letters sent to the Veteran in June 2004, October 2006, March 2007, December 2009, January 2010, October 2008, October 2011, August 2012, and May 2017. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service, VA, and private treatment records are associated with the claims file as are records associated with his claim for disability benefits from the Social Security Administration (SSA). VA provided relevant examinations as discussed in further on in the decision. There is no indication of additional existing evidence that is necessary for a fair adjudication of the claims that are the subject of this appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. II. Increased Ratings - Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Back Disability In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. The Veteran has recently been rated under DC 5237, which refers to the General Rating Formula for Diseases and Injuries of the Spine. The criteria for rating all spine disabilities are set forth in a General Rating Formula for Diseases and Injuries of the Spine, pursuant to which limitation of motion and other factors are evaluated. Under this general rating formula, a 10 percent rating is warranted for lumbosacral spine disability manifested by forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, or a combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for flexion of the thoracolumbar spine between 30 and 60 degrees, or combined range of motion of the thoracolumbar spine not greater than 120 degrees, or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. A 40 percent rating is warranted where forward flexion of the thoracolumbar spine 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine, and 100 percent rating is contemplated when there is unfavorable ankylosis of the entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. During the course of the appeal, in a May 3, 2011 decision, the Board granted a 10 percent rating for radiculopathy of the left and right lower extremity pursuant to the criteria found at 38 C.F.R. § 4.124a, DCs 8520, 8620 for mild incomplete paralysis of the sciatic nerve. Those criteria provide that an 80 percent rating is assigned where there is complete paralysis of the sciatic nerve, where the foot dangles or drops, there is no active movement possible of muscles below the knee, flexion of the knee weakened or lost. 38 C.F.R. § 4.124a, DC 8520, 8620 (2017). Severe paralysis of the sciatic nerve, with marked muscular atrophy, is rated as 60 percent disabling. Id. Moderately severe, moderate, and mild incomplete paralysis of the sciatic nerve is rated as 40, 20, and 10 percent disabling, respectively. Id. The term "incomplete paralysis" indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. See Note under "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124 (a). When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. Id. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. The Diagnostic Codes for the spine are as follows: 5235 Vertebral fracture or dislocation; 5236 Sacroiliac injury and weakness; 5237 Lumbosacral or cervical strain; 5238 Spinal stenosis; 5239 Spondylolisthesis or segmental instability; 5240 Ankylosing spondylitis; 5241 Spinal fusion; 5242 Degenerative arthritis of the spine (see also diagnostic code 5003); 5243 Intervertebral disc syndrome. In this case, the Veteran has not contended, and the evidence does not show, that the Veteran has residuals of a fracture of the vertebra (DC 5235), sacroiliac injury and weakness (DC 5236), spondylolisthesis or segmental instability (DC 5239), or ankylosing spondylitis (DC 5240), any time during the entire rating period on appeal. As discussed below, the Veteran did have spinal fusion, however, the evidence does not show that an increased rating under DC 5241 is applicable. Accordingly, the diagnostic codes pertaining to those disabilities are not applicable in this case. The Veteran's lumbar spine disability is rated under 38 C.F.R. § 4.71a, DC 5237, applicable to lumbosacral or cervical strain. All diseases and injuries of the spine other than Intervertebral Disc Syndrome (IVDS), however, are rated under the general rating formula for diseases and injuries of the spine (general rating formula). IVDS is rated either under the general rating formula or under the Formula for Rating IVDS based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes provides for a ten percent disability rating for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent disability rating is awarded for disability with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. With incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent evaluation is in order. Finally, a maximum schedular rating of 60 percent is assigned for intervertebral disc syndrome with incapacitating episodes having a total duration of at least six weeks during the past 12 months. Note (1) to the formula for rating intervertebral disc syndrome specifies that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Background Historically, in an October 2007 rating decision, the RO assigned a temporary 100 percent rating for the Veteran's service-connected musculoskeletal low back pain, with dorsal column stimulator implant and continued the 40 percent rating effective November 1, 2008. In a March 2008 rating decision, the RO granted a temporary 100 percent evaluation due to hospital admission on November 21, 2007. An evaluation of 40 percent was reassigned effective January 1, 2008, following one month convalescence. Thereafter, the rating decision code sheet associated with the RO's March 2010 rating decision indicates a 60 percent disability rating is assigned for back disability effective January 1, 2008. In a May 2011 Board decision, the Board found that the Veteran's low back disability merited a 20 percent rating prior to April 11, 2007, and remanded his claim of entitlement to an increased rating for low back disability from April 12, 2007 for further development. The RO implemented the Board's decision in an August 2011 rating decision granting an increased rating from 10 percent to 20 percent prior to October 21, 2004, and effective March 23, 1998. In a December 2013 rating decision the RO reduced the Veteran's low back disability rating from 60 percent to 40 percent effective January 1, 2008. It was determined that there was clear and unmistakable error in a prior rating decision. Specifically, it was determined that "the rating decision dated March 16, 2010 incorrectly backfilled [the Veteran's musculoskeletal low back pain [disability] with an evaluation of 60 percent effective January 1, 2008." It was explained that "the evaluation was coded and input incorrectly, as the previous rating showed [the Veteran's] evaluation for [his] back condition at 40 percent effective January 1, 2008." It was concluded that there was neither evidence at that time showing a 60 percent evaluation was warranted nor was there a claim pending for an increase evaluation. Thereafter, by notice dated in June 2014 the RO informed the Veteran that a March 2010 rating decision assigned an incorrect evaluation of 60 percent for lumbar spine disability and it was proposed to reduce the rating from 60 percent to 40 percent effective January 1, 2008. In a subsequent April 2015 rating decision, the RO decreased the evaluation for lumbar spine disability from 60 percent to 40 percent effective August 1, 2015. This reduction was a separate action by the RO and the RO provided the Veteran and his representative with notice of the decision in a May 2015 letter and included an enclosure that explained his procedural and appellate rights. The Veteran did not initiate an appeal of that April 2015 decision in the year following notification of the decision and there is no issue before the Board as to the propriety of the reduction. The dispositive issue in this case is therefore whether an increased rating is warranted in excess of 40 percent for low back disability from April 12, 2007, in excess of 60 percent from January 1, 2008 to August 1, 2015, and in excess of 40 percent thereafter. Turning to the evidence, pursuant the Board's April 2017 Remand, in correspondence dated in May 2017, the AOJ requested the Veteran submit the information and authorization to obtain medical records from Baptist Medical Center, Mental Health Center of Jacksonville, Brooks Rehabilitation and Devine Therapy, and Wellness of Ocala, FL. In response, in June 2017, the Veteran's representative submitted medical evidence from Baptist Medical Center, The Vines Hospital, and River Point Behavior Health. Additionally, the AOJ also obtained treatment records from Jacksonville OPC and from VA vocational rehabilitation. A. April 12, 2007 to September 3, 2007 From April 12, 2007 to September 3, 2007, the Veteran's lumbar spine disability was assigned a 40 percent disability rating. On examination in April 2007, the Veteran reported constant low back pain worsened by prolonged sitting, walking, and standing, and radiated down both legs in the front. He reported stiffness in the back and denied flare ups. He reported numbness and weakness in both legs, an unsteady gait, and falling. He also reported bowel and bladder problems. Treatment included physical therapy and medication. He also used a cane for support and assistance with balance. Physical examination indicates there wad flexion from 0 to 20 degrees, with pain, extension from 0 to 5 degrees, with pain, lateral flexion from 0 to 10 degrees bilaterally, and lateral rotation from 0 to 10 degrees bilaterally. There was no change in range of motion with repetition. The examiner concluded that the Veteran is not experiencing a flare up of the condition during current examination, therefore it would be speculative to provide an opinion on limitation during a flare up. The examiner noted there was limitation with standing and walking due to slowness and antalgic gait and there was no ankylosis of the lumbar spine. There was normal strength in the lower extremities and sensory exam revealed decreased light touch to the lower left leg. Deep tendon reflexes were 1 plus. X-rays revealed degenerative changes and the examiner diagnosed lumbosacral strain. B. September 4, 2007 to December 31, 2007 During this period of the appellate term, with the exception of the period from November 1, 2007 to November 20, 2007, the Veteran was assigned a 40 percent disability rating. The evidence of record during this period does not reflect that the Veteran had unfavorable ankylosis of the entire thoracolumbar spine or the entire spine or that he had incapacitating episodes that would warrant a higher rating. From September 4, 2007 to October 31, 2007 and November 21, 2007 to December 31, 2007, the Veteran was assigned a temporary 100 percent disability rating. As this is the maximum rating allowed the Board will not address these periods on appeal. C. January 1, 2008 to Present Turning to the evidence, pertinent evidence during this period of the appellate term includes private treatment records and VA treatment records. The Veteran was afforded VA examinations of the spine in February 2010, October 2011, September 2012, and August 2016. The examination reports indicate that the examiners reviewed the Veteran's claims file and medical records in conjunction with the evaluation. On examination in October 2011 the Veteran reported persistent low back pain with radiating pain and numbness. The Veteran reported flare ups precipitated by lifting, bending, sitting more than 30 minutes, standing more than a few minutes, and weather changes approximately once a week for 1 day. Symptoms are alleviated by rest and medication. Physical examination indicates there was flexion to 25 degrees, with pain at 15 degrees, extension to 5 degrees, without painful motion, lateral flexion from 15 degrees bilaterally, with pain at 10 degrees, and lateral rotation from 25 degrees bilaterally, with pain at 20 degrees. On repetitive range of motion testing there was flexion to 25 degrees, extension to 5 degrees, lateral flexion to 15 degrees bilaterally, and lateral rotation to 25 degrees bilaterally. There was no additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing. There was less movement than normal, weakened movement, excess fatigability, and pain on movement following repetitive-use testing. There was localized tenderness or pain to palpation of the spine tissue and joints. The Veteran's gait was abnormal described as slow with a stooped posture. He required constant use of assistive devices to include wheelchair, brace, cane, walker, and scooter. X-rays of the lumbar spine identified arthritic sclerosis On examination in September 2012 the Veteran reported back pain and denied flare-ups. Physical examination indicates there was flexion to 10 degrees, with pain at 5 degrees, extension to 5 degrees, with pain at 5 degrees, lateral flexion from 5 degrees bilaterally, with pain at 5 degrees, and lateral rotation from 5 degrees bilaterally, with pain at 5 degrees. The Veteran was unable to complete repetitive range of motion testing due to pain. However, the examiner indicated there was additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing as well as functional loss and/or functional impairment of the thoracolumbar spine of less movement than normal, weakened movement, pain on movement, and disturbance of locomotion. There was localized tenderness or pain to palpation of the spine tissue and joints, and guarding or muscle spasm but did not result in abnormal gait or spinal contour. There was no ankylosis. On VA examination of the back in August 2016 the Veteran denied flare-ups and did not report having any functional loss or functional impairment of the thoracolumbar spine. He reported daily low back pain that radiates down causing his feet to feel numb. Examination of the spine revealed abnormal range of motion. There was flexion to 50 degrees, extension to 30 degrees, lateral flexion to 30 degrees bilaterally, and lateral rotation to 30 degrees bilaterally, with no objective evidence of pain on examination or evidence of pain with weight-bearing. The examiner opined that abnormal range of motion itself did not contribute to a functional loss and there was no additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing. There was no localized tenderness or pain to palpation of the spine tissue and joints. There was guarding that did not result in abnormal gait or spinal contour. The examiner indicated that that it was obvious guarding was voluntary when any part of the Veteran's back was touched. The examiner noted that when he was encouraged to relax he was able to do so. The examiner concluded that the Veteran's subjective complaints on examination were out of proportion to objective examination findings. The Veteran was not examined immediately after repetitive use over time and the examiner found that it was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use. This examiner was unable to say without mere speculation whether pain, fatigue, weakness, and incoordination significantly limited functional ability with repeated use over a period of time. The examiner explained that there was no additional range of motion loss due to pain, weakness, fatigability, or incoordination significantly limiting functional ability when the joint was used repeatedly on current examination. VA and private treatment records do not show there is ankylosis of the thoracolumbar spine. VA treatment records show that the Veteran presented with complaints of low back pain and pain in the bilateral lower extremities. He endorsed symptoms of radiating pain down the legs, tingling, and numbness. He was diagnosed with radiculopathy. Private treatment records from Jacksonville Spine Center show degenerative disc changes at L3-4 and L4-5 and spondylosis identified by x-rays. Treatment records dated from February 2009 to July 2010 show the Veteran presented with complaints of back pain and bilateral leg pain. He walked with an antalgic gait using a cane for stabilization. He reported intense pain with standing for longer than 5 minutes. It is noted that he had lumbar epidural steroid injections with minimal benefit as well as several surgeries to include spinal cord stimulator. He denied change in bowel or bladder. Decreased sensation to light touch in the lateral aspect of the lower extremities was also noted. Deep tendon flexes were 2 plus in the lower extremities and muscle strength testing was also a normal 5/5. There was also limited range of motion with flexion, extension, and rotation of the lumbar spine, with pain on motion but the results were not provided in terms of degree. River Point Behavior Health private treatment records include a November 2015 psychiatric evaluation, which indicates on physical examination the Veteran presented with complaints of back pain, which caused him to walk with an unsteady gait for which he is using a cane for support. The Veteran's back disability has been manifested by pain, significant limitation of motion, and complaints of left and right lower extremity radiculopathy manifested by tingling, numbness, and decreased sensation. When these symptoms are applied to the rating criteria, they are consistent with the current 40 percent rating. 38 C.F.R. § 4.71a , DC 5237. A higher rating requires unfavorable ankylosis of the thoracolumbar spine. Id. In this case, no ankylosis, favorable or unfavorable, is shown on the record. Neither the Veteran's lay statements nor the VA examination reports, nor private, VA, or SSA records indicate that there was unfavorable ankylosis of the entire thoracolumbar spine or the entire spine. Rather, these documents contain either specific findings of no ankylosis or range of motion figures reflecting that there is no ankylosis. Thus, an increased rating higher than those assigned is not warranted at any period during the appellate term. The Board is aware of the Court's decision in Correia v. McDonald, Vet. App. No. 13-3238 (2016) (holding that § 4.59 requires that the listed range of motion testing be conducted to the extent practicable in all cases involving joint disabilities); however, given the Veteran is receiving the maximum rating based on limitation of motion of the spine and a higher rating requires ankylosis, there is no prejudice in the VA examination not having conformed to 38 C.F.R. § 4.59 as interpreted in Correia. Radiculopathy of the Left and Right Lower Extremities Here, the Veteran has been awarded a 10 percent rating for radiculopathy of the left lower extremity and a separate 10 percent rating for radiculopathy of the right lower extremity effective September 23, 2002. As discussed above, DC 8520 provides the rating criteria for paralysis of the sciatic nerve, and therefore neuritis and neuralgia of that nerve. Disability ratings of 10 percent, 20 percent and 40 percent are assignable for incomplete paralysis that is mild, moderate or moderately severe in degree, respectively. 38 C.F.R. § 4.124a, DC 8520. Applying these criteria to the facts of this case, the Board finds that the Veteran has mild incomplete paralysis of the right and left sciatic nerve, which warrants a separate 10 percent rating for each lower extremity. As discussed below, the Board finds that the evidence does not warrant an additional rating or higher rating in excess of the assigned separate 10 percent rating for each lower extremity during any period on appeal. The VA examinations and the VA and private treatment records demonstrate that the Veteran has been repeatedly diagnosed with radiculopathy in his lower extremities. Additionally, throughout his appeal, the Veteran has consistently reported numbness and tingling in his bilateral lower extremities. The Veteran is not entitled to a higher 20 percent rating for each extremity under DC 8520 since the evidence of record does not establish that his incomplete paralysis of the sciatic nerve is moderate in either lower extremity. Specifically, the November 2000 VA examiner determined that the Veteran's sensations were intact throughout both of his lower extremities. In November 2001, the Veteran's private physician characterized the Veteran's radiculopathy as mild. Additionally, at the April 2002 VA examination, the VA examiner, following a review of the claims file and a physical examination of the Veteran, determined that his lower extremity sensory loss was mild. At the October 2004 VA examination, the VA examiner, following a review of the claims file and a physical examination of the Veteran, determined that the Veteran had "feeling to light sensation" over his bilateral feet. An April 2007 VA neurology examination indicates no objective clinical evidence of lumbosacral radiculopathy and also that sensory polyneuropathy of the right and left lower extremities was unrelated to musculoskeletal low back pain. A November 2009 podiatry consult shows sensation was weak, 1/5 with normal muscle strength within normal limits, with normal range of motion. His gait was observed as difficult and the Veteran used a walker and cane for support. He was assessed with foot pain, neuropathy, and gait difficulty. On VA neurological disorders examination on October 2011, the resulting examination report indicates the Veteran reported a history of intermittent, diffuse pain, numbness, and tingling down the left lower extremity occurring primarily on activity. Examination of the lower extremities revealed a normal neurological exam. Muscle strength and sensory examination were normal. Deep tendon reflexes were also 2 plus normal and gait and tandem gait were normal. The examiner concluded there was no objective evidence of radiculopathy or neuropathy on clinical examination of the bilateral lower extremities. It was also noted that the Veteran did not require any assistive device and performed activities of daily living to include his occupation as a police officer without any limitations. There were also no incapacitating episodes of IVDS within the past 12 months. In a September 2011 statement, the Veteran requested a temporary 100 percent disability rating for surgery related to radiculopathy of the right and left extremities based on mild paralysis of the sciatica nerve. In a separate September 2011 statement the Veteran requested an increased rating for these disabilities. In a September 2012 rating decision the RO continued the separated 10 percent ratings for radiculopathy of the lower right and left extremities. On examination in October 2011, the Veteran had full muscle strength of his lower extremities without atrophy and deep tendon reflexes were 2 plus normal for the knees and 1plus hypoactive for the ankles. Sensory testing showed decreased sensation in the lower legs and feet, otherwise sensory test results were normal. Straight leg raising test results were positive for the right and left lower legs. He did exhibit radicular pain and symptoms of radiculopathy to include moderate constant pain, mild intermittent pain and moderate paresthesias and/or dysesthesias of the bilateral lower extremities. There was also moderate numbness in the right lower extremity and mild numbness in the left lower extremity. The examiner opined that the Veteran's incomplete paralysis of the right and left lower leg, involving the sciatic nerve was moderate. An August 2012 VA peripheral neuropathy examination indicates diagnoses of sensory polyneuropathy of the right and left lower extremities. He did exhibit radicular pain and symptoms of radiculopathy to include severe constant and intermittent pain, sever parethesias and/or dysesthesias, and severe numbness of the right and left lower extremities. Muscle strength was normal with no atrophy. Deep tendon reflexes were 0, absent and sensory results were absent. The Veteran used a cane regularly and his gait was described as slow to prevent pain and ensure safety. Examination and EMG studies identified normal right and left extremities and the examination report indicates that all nerves, to include the sciatic nerve were normal. A September 2012 VA examination identified muscle strength was normal with no atrophy. Deep tendon reflexes were also normal. There was also abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. There was no IVDS. There was decreased sensation in the lower legs and feet, otherwise sensory test results were also normal. Straight leg raising test results were negative. He did exhibit radicular pain and symptoms of radiculopathy of mild numbness of the bilateral lower extremities. The examiner opined that the Veteran's incomplete paralysis of the right and left lower legs, involving the sciatic nerve was mild. On VA examination in August 2016, muscle strength was normal with no atrophy. Deep tendon reflexes were a hypoactive 1 plus and sensory testing was normal. There was also abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. There was no IVDS. There was decreased sensation in the lower legs and feet, otherwise sensory test results were also normal. Straight leg raising test results were negative. He did not exhibit radicular pain and symptoms of radiculopathy of either lower extremity. There was also no bowel or bladder problems, IVDS, and the Veteran's spine was not ankylosed. He reported occasional use of a cane and electric scooter as well as regularly using a walker. He explained using a cane and walker helped him to walk quicker and also exercise. The examiner note the Veteran exited with a cane in and out of the exam room to his electric scooter in no distress. The examiner diagnosed musculoskeletal low back pain, with dorsal column stimulator implant. The examiner concluded examination revealed no evidence of radiculopathy or neuropathy to explain the Veteran's subjective complaints of radiating pain down both legs as examination revealed no objective evidence of sensory or motor deficit. The October 2011 VA examination report and treatment records reflect diagnosis of IVDS, however, lack of incapacitating episodes (as defined in Note 1 to the formula for rating IVDS) was noted on the October 2011 VA examination report and incapacitating episodes were not otherwise noted. Similarly, the Veteran has not reported experiencing incapacitating episodes for which he was prescribed bed rest. Thus a higher schedular rating available under the formula for rating IVDS based on incapacitating episodes is not warranted. Based on the above, the Board finds that the evidence of record establishes that the Veteran's incomplete paralysis of the sciatic nerve is best rated as mild in each lower extremity. 38 C.F.R. § 4.124, DC 8520. Based on the pertinent evidence set forth above, the Board determines that any staged ratings higher than those already assigned is not warranted at any time during the appellate term. The Board acknowledges the Veteran's statements describing symptoms of his back and bilateral lower leg disabilities to include back pain and stiffness, radiating pain down both legs, numbness and weakness in both legs, an unsteady gait, and falling. The Veteran is competent to report the symptoms associated with his service-connected disabilities and the extent of his impairment to include during flare ups of symptoms and the Board has no reason to challenge the credibility of his contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). These statements describe symptoms of the Veteran's back and bilateral lower leg disabilities, particularly pain worsened by prolonged walking, sitting, and standing. The Board also acknowledges the Veteran reports constant use of assistive devices to include wheelchair, brace, cane, walker, and scooter to support ambulating. They are consistent with the observations noted on the VA examinations and treatment records. Here, the Board finds the objective clinical findings by medical professionals aware of his symptoms more probative than the Veteran's statements. The examiners are medical professionals, and they were able to review the overall record, including the Veteran's history and opinions. As discussed above, examinations were provided to ensure that the record reflects the current extent of these disabilities, and these findings are responsive to the pertinent rating criteria. Finally, consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a schedular rating in excess of that assigned. For all the foregoing reasons, the Board finds that, there is no basis for further staged rating for the Veteran's musculoskeletal low back pain with dorsal column stimulator implant disability with associated radiculopathy of the left and right extremities based on mild paralysis of the sciatica nerve, pursuant to Hart, and that the claim for a higher rating for the disability is not warranted at any time during the appeal period and must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher ratings, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Psychiatric Disability The Veteran's schizoaffective disorder and major depressive disorder with psychotic features is rated under 38 C.F.R. § 4.130, DC 9400. As noted, all psychiatric disabilities are now rated under the general rating formula for mental disorders. The Board notes that, effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders, including 38 C.F.R. § 4.130, to remove outdated references to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and replace them with references to the recently updated Fifth Edition (DSM-5). See Final Rule, Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14308 (Mar. 19, 2015). As the provisions of this amendment were not intended to apply to claims that had been certified for appeal to the Board on or before August 4, 2014, see id., and this case was certified and re-certified to the Board prior that date, the Board will not consider them in this decision. The Veteran's schizoaffective disorder and major depressive disorder with psychotic features is rated 40 percent under the general rating formula from February 10, 2003, the criteria for which are noted above. This rating is derived from the Board's April 2016 decision, granting an evaluation of 70 percent for occupational and social impairment with reduced reliability and productivity, discounted by a 30 percent rating for primary psychiatric illness existing independent of the low back disability. A 70 percent 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); and inability to establish and maintain effective relationships. The maximum schedular 100 percent rating is warranted for 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. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be 'due to' those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Global Assessment of Functioning (GAF) is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing DSM-IV). As will be discussed below, the Veteran has been assigned GAF scores ranging from 10 to 60 as determined by treatment providers and VA examiners. These scores are indicative of moderate to very serious impairment. According to the DSM-V, which VA has adopted pursuant to 38 C.F.R. §§ 4.125 and 4.130, GAF scores of 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). Scores of 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed adult avoids friends, neglects family, and is unable to work). Scores ranging from 21 to 30 reflect behavior that is considerably influenced by delusions or hallucinations, serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation), or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). Scores ranging from 11 to 20 reflect some danger of hurting self or others (e.g. suicide attempts without clear expectation of death; frequently violent; manic excitement), occasionally fails to maintain minimal personal hygiene (e.g., smears feces), or gross impairment in communication (e.g., largely incoherent or mute). Scores from 1 to 10 indicate persistent danger of hurting self or others (e.g., recurrent violence), persistent inability to maintain minimal personal hygiene, or serious suicidal act with clear expectation of death. The Veteran's claim for an increased rating was received in February 2003. An October 2005 rating decision denied an increased disability rating in excess of 20 percent. These decisions explained that an evaluation of 20 percent was assigned for aggravation of a nonservice-connected disability by a service-connected disability by subtracting the evaluation of the pre-existing primary psychiatric disability (30 percent) from the overall evaluation of the disability (50 percent). In an April 2016 decision, the Board increased the 20 percent disability rating to a 40 percent rating, effective February 10, 2003, for the psychiatric disorders and awarded a total rating based on individual unemployability due to service connected disabilities (TDIU). As discussed in the Board's April 2016 decision, the Board has thoroughly reviewed the record and finds that the most probative evidence shows that the Veteran's symptoms of schizoaffective disorder and depressive disorder with psychosis have been consistent and are of such severity as to warrant a 70 percent evaluation throughout the rating period on appeal. After offsetting this rating with the 30 percent previously determined to exist prior to aggravation by the Veteran's service-connected low back disorder, this amounts to a 40 percent rating. Turning to the evidence, in May 2000, the Veteran underwent a psychological assessment at the VA. The psychologist noted that the Veteran had extremely elevated F scores on Minnesota Multiphasic Personality Inventory testing, indicating exaggeration of symptoms. The psychologist noted that elevated F scale scores have been associated with recognition of possible financial gain through exaggerated endorsement of pathology. The Veteran attempted suicide on December 31, 2002, and was hospitalized at Baptist Medical Center from January 1 to January 4, 2003. He had four past suicide attempts, and reported that he wanted to kill himself due to chronic pain. He had crying spells, sadness, and feelings of helplessness and worthlessness. He had heard voices since 1995 and had occasional homicidal ideations. His wife left him on January 5, 2003. His GAF was 30 on January 2, 2003 and 50 at discharge on January 4, 2003. The Veteran's ex-wife submitted a statement in July 2004, stating she was divorcing the Veteran due to his mental health. She stated the Veteran's medication makes him delusional and have hallucinations. She stated she would find him hiding in the closet from "enemies," and he would go into a daze and forget what they were talking about in the middle of a conversation. The Veteran's roommate also submitted a statement in July 2004. The roommate reminded the Veteran to complete personal hygiene tasks, take his medication, and dress appropriately. In April 2003 and July 2003, the Veteran reported he had plans to visit his mother and his daughters. An April 2003 VA treatment record notes he was able to differentiate reality from his hallucinations. An August 2003 VA treatment record noted the Veteran had suicidal thoughts, but no plan. He had received morphine for his pain, which also helped to relieve the suicidal thoughts. He said he hears voices that tell him to harm himself and others. He had mood swings, difficulty sleeping, and low energy. He reported he did not have many friends, as he doesn't trust people and is sensitive to criticism. He did not even trust his wife, and would not eat her cooking because he thought she was trying to poison him. He was oriented, had clear thought processes, and normal speech. His GAF was 50. Records note that the Veteran was hospitalized at a private hospital in June 2003 for depression and in September 2004 for suicidal ideations and auditory hallucinations. VA treatment records from 2003 to 2011 show the Veteran participated in group therapy for schizophrenia and related psychotic disorders. He was generally appropriate with the group, with the exception of an incident in December 2005, when he got into an argument with another group member. The Veteran had a VA psychiatric examination in October 2005. He reported two hospitalizations in the past year for suicidal thoughts, as well as another hospitalization for suicidal thoughts in 2004. He estimated a total of nine psychiatric hospitalizations since 1990. He had previously attempted suicide by running his car into a bridge, after which he awoke in a hospital. In his most recent suicide attempt, he had put a gun to his mouth, but was discovered by a friend. He reported that his wife had left him, but he had a female friend who stays with him and helps him. He was close to his two daughters and had about five friends. The Veteran reported that his auditory hallucinations had begun in 1981 while he was in the military, about six to seven months after experiencing a head injury. He stated that he hears two voices. He also reported visions of the persons with the voices, but when asked to describe them, gave very vague descriptions. He endorsed delusions, stating that the television and radio were talking about his life, as well as delusional beliefs about thought insertion and mind control. He reported sleeping only four to five hours per night. The Veteran had positive hygiene and grooming, and was alert and fully oriented except that he misstated the correct date by one day. The examiner noted that while the Veteran reported hearing voices during the examination, he did not seem distracted by auditory hallucinations. The examiner also noted that he did not exhibit disorganized speech, flattened or inappropriate affect, or poor hygiene/grooming, which is typical of psychotic individuals. The examiner opined that the Veteran was either fabricating or exaggerating his account of the hallucinations. The examiner rated his GAF at 60. On a November 18, 2005, VA treatment visit, the Veteran reported "fighting with death." He said the voices tell him to "pull his skin back so that they can get out," so he cut himself on his left wrist. He was involuntarily admitted for psychiatric treatment at the VA Medical Center and discharged on December 2, 2005. VA treatment records in 2006 note the Veteran's report of increased psychiatric symptoms with increased pain from his other conditions. For example, in March 2006, the Veteran stated he ran out of pain medication, and the voices and suicidal thoughts increased. When he was able to receive his pain medication, he started to feel better. The Veteran was admitted to the VA for in-patient psychiatric treatment from May 6, 2008 to May 13, 2008. He reported feeling "trapped in a life of constant pain and looking for a way out," and said that his pain led him to think about hurting himself and others. He had continued auditory hallucinations telling him things, including urging him to kill people. He presented with severe chronic back pain. At admission, his GAF was rated at 10 to 20, and was rated at 50 on discharge. Private records from The Vines Hospital show the Veteran was admitted for inpatient psychiatric care on February 15, 2011 and discharged on February 19, 2011 with multiple admitting diagnoses to include mood disorder and chronic back pain. On discharge diagnoses included mood disorder, degenerative disc disease, and chronic pain. He reported voices, suicidal thoughts, sleep disturbance due to chronic pain and nightmares, and low energy. He had circumstantial thought processes. On February 14, 2011, he presented himself with two personalities to the attending psychiatrist. The first personality ("A") was depressed, while the other ("D") wanted to kill "A" and hurt other people. His GAF was rated at 20. Psychiatric evaluation on admission indicates the Veteran was admitted from the VA due to psychiatric problems reported by the Veteran. He reported symptoms of audio hallucination, depression, anxiety, short term memory problems, social withdrawal, difficulty sleeping, and short attention span. He denied suicidal and homicidal ideations. Mental status examination indicates the Veteran's speech was coherent and relevant and he was oriented to time, person, and place. His memory was normal and insight and judgment were fair. His mood was noted as depressed. There were no psychotic symptoms. At an October 2011 VA examination, the Veteran was diagnosed with mood disorder and chronic pain. He endorsed hearing voices, suffered from anxiety, and had difficulty sleeping at night due to pain. His mood was managed by medication. The examiner noted that the last VA examination showed evidence of malingering. The examiner found that the Veteran had occupational and social impairment due to mild or transient symptoms, which decrease work efficiency and ability to perform occupation tasks. The symptoms were controlled by medication or only present during periods of significant stress. The examiner opined that it was difficult to provide an unemployability statement, as it was unclear whether some of the Veteran's asserted psychiatric symptoms were legitimate or not. The examiner stated that the Veteran may have some concentration and attention problems, and that his variable mood, influenced by chronic pain and maladaptive coping, may interfere with interpersonal relationships in a workplace. Private treatment records from River Point Behavior Health show the Veteran was admitted for inpatient psychiatric care from June 18, 2015 to June 24, 2015 after attempting to set himself on fire and threatening to jump off a bridge. He appeared to be having auditory hallucinations, intermittently displayed. He was again hospitalized on November 2, 2015 and discharged on November 30, 2015. On psychiatric evaluation the Veteran endorsed symptoms of paranoid hallucinations but was unable to confirm by providing examples. He also reported auditory hallucinations and denied suicidal ideation. The examiner noted he has morbid thoughts, which were "lighter in intensity." Treatment included antipsychotic medication and participation in group therapy. Mental status examination indicates his judgment and insight were intact. He was oriented to his surroundings. The examiner, a medical doctor diagnosed schizoaffective disorder, dissociative identity disorder and PTSD. An October 2015 record indicates the Veteran reported suicidal ideation. He was treated for depression and psychosis. An August 2016 VA mental disorders Disability Benefits Questionnaire, diagnosed major depressive disorder with psychotic features manifested by depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbance of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a work like setting. Following claims file review and examination; the examiner opined that the Veteran's symptoms caused occupational and social impairment with reduced reliability in productivity. The resulting examination report indicates the Veteran did not report having any difficulty with maintaining relationships with family or friends. He reported having three friends with whom he maintains contact and that he resides with his wife of 9 years and their adult daughter. He reported hobbies and volunteer work with daycare kids. On examination his appearance and hygiene were good. He was fully oriented, polite, and cooperative. His speech was coherent. There was no evidence of psychosis. He reported that internal voices and paranoia were under control and treatment to include therapy and medication. He also denied suicidal ideation and homicidal ideation. The examiner assigned a GAF score of 50-55. After a thorough review of the evidence, the Board finds that the impact of the Veteran's psychiatric illness on his social and occupational functioning is sufficient to approximate no more than the degree of impairment contemplated by a 70 percent rating. In this regard, the Board acknowledges that the GAF scores assigned to this disability have reflected various levels of impairment-from moderate to serious. However, it is the symptoms specifically noted in the Veteran's VA examinations, treatment records, and personal statements that are of the utmost significance. Additionally, the Board has considered the statements from the Veteran and his ex-wife, as well as the statement of his roommate. The Veteran, his family and friends are competent to report the symptoms associated with his service-connected disabilities and the Board has no reason to challenge the credibility of these contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). These statements describe symptoms of the Veteran's schizoaffective disorder and major depressive disorder with psychotic features, particularly his anxiety, depression, sleep difficulties, paranoia, suicide attempts, auditory hallucinations, and chronic pain. They are consistent with the observations noted on the VA examination reports and treatment records. The Veteran's roommate reported he assisted with reminding the Veteran to complete personal hygiene rituals and to take medication. Notably, during the appellate term, treatment records and VA examination reports indicate the Veteran had positive hygiene and grooming. Based on the pertinent evidence set forth above, the Board finds that the symptomatology associated with the Veteran's service-connected schizoaffective disorder and depressive disorder with psychosis have been shown to result in occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. The Veteran has exhibited symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, circumstantial speech, impaired judgment, disturbances of motivation and mood, difficulty in establishing effective work and social relationships, suicidal ideation and intermittent danger to himself or others, speech intermittently illogical, obscure or irrelevant, impaired impulse control, and persistent delusions or hallucinations. 38 C.F.R. § 4.130, DC 9411. Specifically, these symptoms have been endorsed by the Veteran, as well as the VA and private treatment providers/examiners. While there have been some questions of malingering, the behaviors of the Veteran have caused his wife to leave and he has also had numerous hospitalizations and instances of self-harm. The Board recognizes that the Veteran has been hospitalized due to his psychiatric disabilities during the period on appeal. However, the evidence does not show that any of these hospitalizations included surgery or immobilization, or exceeded 21 days, as is required for a temporary total disability rating under 38 C.F.R. §§ 4.29, 4.30. The Board also recognizes that the Veteran was not employed during the period under consideration. However, no medical professional has provided any opinion indicating that the Veteran's psychiatric symptoms alone have caused total occupational and social impairment. In this regard, he has been married three times, endorses a good relationship with his daughter, reported having friends, and has consistently attended group behavioral therapy and behaved appropriately. Moreover, he has consistently demonstrated appropriate hygiene, and his thought processes and ability to communicate have been generally intact throughout the appeal period. While he has consistently endorsed auditory hallucinations, examiners have noted he was able to discern reality from hallucinations. Further, some examiners have expressed concerns about malingering or the exaggeration of symptoms. Thus, in this case, the symptoms shown in the record do not equate to total occupational and social impairment. Based on this evidentiary posture, the Board concludes that the totality of the evidence of record has shown that the Veteran's schizoaffective disorder with psychosis warrants no more than the 40 percent evaluation currently assigned, which is based on meeting the 70 percent criteria followed by the 30 percent offset III. Extraschedular The Board has considered whether referral for an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is warranted in this case. The Board finds that the Veteran's symptoms of musculoskeletal low back pain with dorsal column stimulator implant disability, left and right lower leg radiculopathy of the sciatica nerve, and schizoaffective disorder and major depressive disorder with psychosis are contemplated by the schedular rating criteria. Neither the facts of the case nor the Veteran's allegations raise the issue of extraschedular consideration. Thus, no analysis is required. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016) (holding that an extraschedular analysis is not warranted where it is not "specifically sought by the claimant nor reasonably raised by the facts found by the Board") (citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007). See also Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (explaining that the Board had no obligation to analyze whether referral is warranted for extraschedular consideration if an extraschedular rating is not specifically sought by the claimant or reasonably raised by the facts found by the Board). Similarly, the Board recognizes that a claim for a total rating based on TDIU may be raised as a separate claim, or in the context of an initial rating or a claim for an increase. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009). In this case, in the April 2016 decision, the Board granted a TDIU based on service-connected back and psychiatric disabilities according to the evidence of record. Therefore no further discussion of a TDIU is necessary. ORDER Entitlement to an increased rating in excess of 40 percent for musculoskeletal low back pain with dorsal column stimulator implant disability from April 12, 2007 to December 31, 2007, with exception of the period from September 4, 2007 to October 31, 2007 and November 21, 2007 to December 31, 2007, when a 100 percent temporary disability was awarded, is denied. Entitlement to an increased rating in excess of 60 percent for musculoskeletal low back pain with dorsal column stimulator implant disability from January 1, 2008 to July 31, 2015, is denied. Entitlement to an increased rating in excess of 40 percent for musculoskeletal low back pain with dorsal column stimulator implant disability from August 1, 2015, is denied. Entitlement to an additional rating or higher rating for left leg radiculopathy of the sciatica nerve associated with chronic musculoskeletal low back pain with dorsal column stimulator implant disability currently rated 10 percent disabling since effective September 23, 2002, is denied. Entitlement to an additional rating or higher rating for right leg radiculopathy of the sciatica nerve associated with chronic musculoskeletal low back pain with dorsal column stimulator implant disability currently rated 10 percent disabling since effective September 23, 2002, is denied. Entitlement to an increased rating in excess of 40 percent for schizoaffective disorder and major depressive disorder with psychosis, from February 10, 2003, denied. ______________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs