Citation Nr: 18143103 Decision Date: 10/18/18 Archive Date: 10/17/18 DOCKET NO. 15-08 321 DATE: October 18, 2018 ORDER Entitlement to service connection for bilateral knee condition is denied. Entitlement to service connection for left ankle condition is denied. Entitlement to an initial 100 percent rating for schizophrenia with posttraumatic stress disorder (PTSD) and persistent depression (hereinafter, psychiatric disorder) prior to April 31, 2015 is granted. FINDINGS OF FACT 1. The weight of the probative evidence is against a finding that the Veteran’s currently diagnosed bilateral knee condition either began during or was otherwise caused by his military service. 2. A left ankle condition did not clearly and unmistakably pre-exist service. 3. The weight of the probative evidence is against a finding that the Veteran’s currently diagnosed left ankle condition either began during or was otherwise caused by his military service. 4. Resolving all reasonable doubt in favor of the Veteran, his psychiatric disorder has been productive of total occupational and social impairment for the entire appeal period. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral knee condition have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The presumption of soundness is not rebutted and a left ankle condition did not pre-exist the Veteran’s entry to service. 38 U.S.C. § 1111; 38 C.F.R. §§ 3.303, 3.304(b). 3. The criteria for service connection for a left ankle condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.310. 4. The criteria for an initial 100 percent rating for psychiatric disorder, for the entire period on appeal, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1979 to April 1981. In June 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternately, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Specifically, service connection for some chronic disorders will be rebuttably presumed if manifested to a compensable degree within a year following active service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Certain chronic diseases, including arthritis, may be service connected if manifested to a degree of 10 percent disabling or more within one year after separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. A layperson is competent to report on the onset and continuity of his or her current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See id. (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). The provisions of 38 U.S.C. 1111 provide that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). A pre-existing injury or disease noted at entry will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C. 1153; 38 C.F.R. 3.306. The provisions of 38 C.F.R. 3.306(b) provide that aggravation may not be conceded unless the pre-existing condition increased in severity during service. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to service connection for bilateral knee condition The Veteran contends that his bilateral knee condition is due to military service. The Veteran has a diagnosis of bilateral knee osteoarthritis. As such, element one under Shedden is met. The Veteran stated that during physical training, he hurt his ankle, and it was placed in a cast. After the ankle injury, his knees began to bother him. The Board notes that the Veteran’s service treatment records (STRs) document complaints and treatments for an ankle injury. As such, element two under Shedden is met. However, the Veteran’s STRs do not document complaints, treatments, or diagnosis for a bilateral knee condition, to include osteoarthritis. During his September 1979 Report of Medical Examination: Enlistment and March 1981 Separation examinations, the Veteran’s lower extremities and other musculoskeletal system were noted as being normal. The Veteran stated that he did not have “trick” or locked knees, or arthritis. Additionally, he stated that he did not have any illness or injury other than those already noted. In March 1993, the Veteran was seen at the Brentwood Evaluation and Admissions. His chief complaint was left knee pain. He stated that he injured his knee three years before the evaluation. In February 1994, the Veteran was seen at the Patient Evaluation Center for his left knee pain. He was diagnosed with left knee arthritis. Regarding his right knee, in August 2006, the Veteran stated that he injured his knee a month before the evaluation. He further stated that he was working in his yard and twisted his right knee. Right knee s-ray revealed minimal narrowing medial compartment. A January 2007 x-ray revealed minimal osteoarthritis of both knees. Based on the evidence of record, the Board finds that the Veteran’s bilateral knee condition is not etiologically related to his military service. The Veteran’s STRs do not show complaints or treatments for a bilateral knee condition, to include osteoarthritis. The first medical evidence of left and right knee condition was in 1994 and 2006 respectively, i.e., over 13 and 25 years after his discharge from active service. The fact that there were no records of any complaints or treatment involving the Veteran’s bilateral knee condition for many years weighs against the claim. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (it was proper to consider the veteran’s entire medical history, including a lengthy period of absence of complaints). There are also no medical nexus opinions in support of the claim. As such, element three under Shedden is not met. Therefore, service connection on a direct basis is not warranted. Regarding presumptive service connection, the Board finds that service connection for bilateral knee osteoarthritis on a presumptive basis is not warranted as the record does not show evidence of bilateral knee degenerative changes within one year of the Veteran’s separation from active duty. As mentioned above, the first competent evidence suggestive of degenerative changes was in 1994, i.e., over 13 years after discharge. As there is no competent evidence that the disability manifested to a compensable degree within one year of his active service and was not continuous since service, a presumption of service connection under 38 C.F.R. §§ 3.307, 3.309 is not warranted. The Board has considered the Veteran and his representative’s statements regarding the etiology of his bilateral knee condition. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a nexus between the bilateral knee condition and service, is outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Board acknowledges that the Veteran has not been afforded a VA examination for his condition; however, an examination is not warranted as the duty to assist has not been triggered. See McClendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). Although McClendon sets a low bar, that bar has not been met here as there is no indication of a link between the Veteran’s current condition and his active service. At its earliest, the Veteran’s condition was diagnosed in 1994, i.e., 13 years after active service. The only evidence of a possible connection between the Veteran’s current disability and his service are the Veteran’s own broad and conclusory statements that the condition is related to service, and such a statement is not sufficient to trigger VA’s obligation to obtain an examination or opinion. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (holding that conclusory lay assertion of nexus is insufficient to entitle claimant to provision of VA medical examination). In the absence of a nexus, the claim for service connection for bilateral knee condition is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable in the instant appeal. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(b). 2. Entitlement to service connection for left ankle condition The Veteran contends that his ankle condition is due to military service. The Veteran’s STRs document a complaint, treatment, and diagnosis of an ankle condition. During his September 1979 Report of Medical Examination: Enlistment examination, the Veteran noted an ankle injury in 1975. There were no complications and sequalae from the injury. In October 1979, the Veteran was seen for left ankle soreness. He had not experienced any trauma; however, he experienced pain when he placed pressure on the foot. The Veteran felt the pain from his heel moving up three to four inches. He was diagnosed with Achilles Tendonitis. During his March 1981 Separation examinations, the Veteran stated that he did not have foot trouble, and the examiner noted the Veteran’s feet and lower extremities were normal. The Board observes that in September 1979, a left ankle condition was noted at induction. However, there were no complications or sequalae. Therefore, the Board finds that the evidence of record does not show that the Veteran’s current ankle condition clearly and unmistakable pre-existed service. The Board notes that the presumption of soundness on entrance cannot be overcome simply based on the representations of the Veteran of a vague history during the entrance examination or thereafter. See Miller v. West, 11 Vet. App. 345, 348 (1998) (holding that a veteran’s self-report that he had previously suffered from “depression or excessive worry” prior to service was insufficient to rebut the presumption of soundness as was found in 38 U.S.C. § 1111); see also Crowe v. Brown, 7 Vet. App. 238, 246 (1995). Thus, the Board finds the presumption of soundness has attached and has not been rebutted. As such, the appropriate analysis is whether his current ankle condition was incurred during active service. In August 2004, the Veteran was seen at the Loma Linda HCS: Nursing Note. He complained of periodic left ankle pain and swelling. In October 2004 and November 8, 2011, the Veteran underwent x-rays for his painful left ankle. The October x-ray revealed no bony or joint space abnormality, and the November x-ray revealed no fractures or soft tissue abnormalities. The examiner concluded that the Veteran’s left ankle was normal. In November 25, 2011, the Veteran was afforded a VA examination to determine the nature and etiology of his ankle condition. The Veteran stated that he had long standing left ankle pain. He stated that he twisted his left ankle during basic training. Since the incident, the Veteran reported constant lateral ankle pain, worse with use, and associated with crepitus. Depending on the activity level, his pain waxed and waned. The Veteran used a walker and cane as a normal means of locomotion. He also took oral medications for partial symptom relief. The examiner noted that the Veteran had or has been diagnosed with left ankle Achilles Tendonitis and chronic ankle sprain. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that the Veteran provided a history with a traumatic sprain and the physical exam demonstrated lateral and anterolateral tenderness with no laxity or subluxing tendons. Therefore, the examiner concluded that the diagnosis provided during the interview and VA exam would be consistent with chronic ankle sprain. The examiner noted that the Veteran’s c-file denoted atraumatic posterior heel/ankle pain that was diagnosed at the time as Achilles Tendonitis. The examiner stated that these are separate entities, and the Veteran did not show signs of Achilles Tendonitis on the VA exam. The examiner further stated that it is possible that the Veteran had an ankle sprain during military service, but there is no documentation found to support this. Imaging showed no abnormal findings. In December 2011, the Veteran was afforded another VA examination to determine the nature and etiology of his left ankle condition. The examiner noted that the Veteran had or has been diagnosed with left ankle Achilles Tendonitis. The examiner opined that the claimed condition (ankle fracture) which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner stated that the Veteran gave a history of a traumatic sprain with recurrent instability symptoms. The Veteran’s STRs showed a diagnosis of a traumatic Achilles Tendonitis unrelated to his reported traumatic sprain. Additionally, the exam requested an opinion relating to a pre-existing fracture, and whether it was aggravated by military service. With the evidence present in the Veteran’s c-file, the examiner opined that the Veteran’s condition and documented ankle pain in-service was not an aggravation of a previous ankle fracture. The examiner stated that there is a diagnosis of Achilles Tendonitis which is unrelated to his previous (healed) fracture. The examiner further stated that there is no documentation to support an aggravation of ankle pain secondary to old/healed fracture prior to service. In June 2018, the Veteran testified that he injured his ankle during physical training. He stated that he was in a cast for approximately four to six weeks. He further stated that due to the ankle injury, he was removed from physical training for the entire training and put on casual duty. Based on the evidence of record, the Board finds that service connection for left ankle sprain is not warranted. The Veteran’s STRs documents complaints, treatments, and/or diagnoses for left ankle Achilles Tendonitis but not left ankle sprain. The November 2011 VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner further stated that Achilles Tendonitis and a sprain are separate entities, and the Veteran did not show signs of Achilles Tendonitis on the VA exam. The examiner noted that it was possible that he had an ankle sprain during military service, but there was no documentation found to support this. As noted above, the Veteran is presumed sound. However, in December 2011, VA obtained a medical opinion to determine if the Veteran’s healed fracture aggravated his current condition beyond its natural progression. The examiner stated that there is a diagnosis of Achilles Tendonitis which is unrelated to the Veteran’s previous (healed) fracture. The examiner further stated that there is no documentation to support an aggravation of ankle pain secondary to old/healed fracture prior to service. Additionally, the Board notes that the first medical evidence of left ankle sprain was in 2004, i.e., over 23 years after his discharge from active service. The fact that there were no records of any complaints or treatments involving the Veteran’s left ankle sprain for many years weighs against the claim. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (it was proper to consider the veteran’s entire medical history, including a lengthy period of absence of complaints). Accordingly, the Board finds that service connection is not warranted. The Board has considered the Veteran’s statements regarding the etiology of his left ankle condition. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a nexus between the left ankle condition and service, is outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In the absence of a nexus, the claim for service connection for left ankle condition is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(b). Increase Rating Entitlement to an initial rating in excess of 50 percent for psychiatric disorder prior to August 31, 2015 A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on the social and occupational impairment, rather than solely on the examiner’s assessment of the level of disability at the time of examination. The rating agency will consider the extent of social impairment, but shall not assign an evaluation solely based on social impairment. 38 C.F.R. § 4.126. The Veteran’s psychiatric disorder is rated under the schedule of ratings for mental disorders, 38 C.F.R. § 4.130. In relevant part, the rating criteria are as follows: A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 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 that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 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. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Although the Veteran’s symptomatology is the primary consideration, the Veteran’s level of impairment must be in “most areas” applicable to the relevant percentage rating criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans’ Claims stated that “a veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’ in order to prevail.” To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). Analysis In a January 2014 rating decision, the agency of original jurisdiction (AOJ) granted service connection for psychotic disorder with paranoid features, schizophrenia, depressive disorder, NOS and assigned a 50 percent rating effective September 13, 2010. The Veteran disagreed with the evaluation and effective date of the evaluation. In an August 2016 rating decision, the AOJ increased the rating for schizophrenia with PTSD, and persistent depression (previously rated as psychotic disorder with paranoid features, schizophrenia, depressive disorder, NOS) to 100 percent effective August 31, 2015. The Veteran file a notice of disagreement disagreeing with the effective date of the 100 percent rating. He contends that prior to August 31, 2015, his psychiatric disorder was worse than the 50 percent rating depicted. In December 2004, the Veteran was seen at the Loma Linda VAMC. He appeared disheveled and malodorous and made poor eye contact. He exhibited mild psychomotor retardation. The Veteran’s speech was of decreased volume and rate, increased latency, and he was mumbling. The Veteran was depressed, and his affect was tearful. His thought process was tangential. He had passive suicide ideations with no plan. He denied homicidal ideation, delusions and auditory hallucinations. He experienced visual hallucinations but refused to elaborate on the details. The Veteran was oriented times three. His memory was intact, and his insight and judgment were poor. In February 2005, the Veteran was seen at the Lima Linda VAMC. The examiner stated that there were no objective signs of PTSD or depression. The Veteran was appropriately dressed and groomed. He cooperated with the examiner and made good eye contact. There were no psychomotor agitation or retardation. His speech was at a normal rate, rhythm, volume, and prosody. The Veteran’s mood was okay, and his affect was constricted. His thought process was linear. He denied suicidal and homicidal ideation and delusions. He also denied auditory and visual hallucinations. He was oriented times three. His insight was poor and judgment was fair. At times, the Veteran became angry for not being compensated. There were no signs of mania or hypomania. In March 5, 2006, the Veteran was admitted to the Loma Linda VAMC. The examiner diagnosed the Veteran with pathological gambling r/o major depressive disorder with psychotic features, r/o PTSD, personality disorder NOS, malingering, and cocaine and alcohol dependence. The Veteran was disheveled. He was cooperative. There were no psychomotor retardation or agitation. His speech was of a normal rate, volume, and tone. The Veteran’s mood was okay, and his affect was flat. The Veteran did not have homicidal or suicidal ideation, visual or auditory hallucinations. His thought process was circumstantial. His insight was poor and judgment lacking. The examiner noted that after the Veteran’s discharge from the hospital in February 2005, the Veteran had been sleeping in his car, and his thoughts were becoming slowed down, and he felt drowsy. The Veteran was asked about suicidal and homicidal ideation. The Veteran stated that “I don’t want to play these games” and “you could be in danger” “anyone who says the wrong thing could be in danger.” He further stated that “yes, I think of hurting myself” “it wouldn’t take much to overdose on those pills.” On March 7, 2006, the examiner stated that, upon discharge, the Veteran’s condition was static and recovery was not expected. On April 12, 2007, the Veteran was seen at the emergency room (ER) for sharp chest pain. Upon discharge, he stated that he was “ready to kill somebody.” He was tangential and vague in his history, and it was difficult to interrupt or get direct answers to questions. The Veteran stated that he was emotionally broken and felt homicidal. He stated that if he went postal, he could plead temporary insanity. He further stated that the government had him in emotional slavery, he believed that he was being followed, his privacy was being invaded, he was being watched, and innocent conversations were subject to perversion by the government. The Veteran denied auditory and visual hallucinations but had a history of hallucinations. The Veteran was compliant with his medication. He denied alcohol or drug use. He endorsed feelings of depression, hopelessness, poor sleep, poor appetite, and passive suicidal ideation. The examiner stated that the Veteran’s most recent admit to the hospital was in March 2006 for suicidal and homicidal ideation with vague presentations. On August 2, 2007, the Veteran was admitted to the Loma Linda VAMC. The examiner diagnosed the Veteran with PTSD, psychosis, substance dependence, gambling, and malingering. The Veteran was agitated and expressed active homicidal ideation. He was talkative, disinhibited, and complained about the government, county, and community. The Veteran’s girlfriend died four years before being admitted to the hospital, and he was also angry and depressed about it. He reported that he could not sleep due to anger towards the governmental agencies. The Veteran was also paranoid. He was discharged on August 6, 2007. At the time of discharge, the Veteran was fairly groomed. He depicted no psychomotor agitation or retardation. He was cooperative. His speech was of a normal rate, volume, and rhythm. He was depressed, and his affect was blunted. His thought process was of paranoia. He denied suicidal or homicidal ideation and auditory or visual hallucinations. He was stable, and his insight and judgment were moderate. The Board notes that the Veteran’s treatment records note ongoing paranoia, persistent delusions, and feelings of hurting himself or others. In December 2013, the Veteran was afforded a VA examination to determine the nature and etiology of his psychiatric disorder. The examiner noted that since November 2003, the Veteran had 14 admissions to the inpatient psychiatric ward. The examiner diagnosed the Veteran with psychotic disorder NOS with paranoid features and depressive disorder NOS. The Veteran’s symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. He experienced occupational and social impairment with reduced reliability and productivity. Based on the evidence of records to include VA treatment records, VA examination report, and the lay statements, the Boards finds that the severity and duration of the Veteran’s symptoms more nearly approximates the criteria for a 100 percent rating under DC 9411. The Board notes that the Veteran has exhibited a variety of symptoms. The Board acknowledges that there has been some degree of fluctuation with respect to the severity of his symptoms. However, after a thorough review of the evidence, and resolving any reasonable doubt in the Veteran’s favor, the Board finds that the disability picture resulting from his symptoms more nearly approximates a 100 percent disability evaluation due to total occupational and social impairment. This is consistent with VA’s determination to handle cases affected by change in medical findings or diagnosis to produce the greatest degree of stability of disability evaluations consistent with the laws and regulations governing disability compensation and pension. See 38 C.F.R. § 3.344(a). In summary, the Board finds that the Veteran’s symptoms during this period more nearly reflect the frequency, severity, and duration of symptoms ratable at the 100 percent disability evaluation. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Henry, Associate Counsel